Nokea
Which of the following findings should prompt the nurse to reassess the client?
- A. Intense contractions lasting 45 to 60 seconds.
- B. Progressive sacral discomfort during contractions.
- C. A sense of excitement and warm, flushed skin.
- D. An urge to have a bowel movement during contractions.
Correct Answer: D
Rationale: An urge to have a bowel movement during contractions may indicate the baby's head is descending, signaling the need to push. This requires reassessment to check dilation. Intense contractions, sacral discomfort, and excitement with flushed skin are normal labor findings.
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Which of the following statements by the newly hired nurse indicates an understanding of the teaching?
- A. The nurse should determine the Apgar score at 2 and 7 minutes after birth.
- B. The nurse should identify that the newborn is in severe distress with an Apgar score of 8.
- C. The nurse should wait for the first Apgar score before initiating resuscitation efforts.
- D. The nurse should measure the newborn's muscle tone when assigning an Apgar score.
Correct Answer: D
Rationale: Measuring muscle tone is part of Apgar scoring (appearance, pulse, grimace, activity, respiration). Apgar is assessed at 1 and 5 minutes, a score of 8 is normal, and resuscitation should not wait for scoring.
Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. We can schedule the procedure for later today if you'd like.
- C. This procedure determines if your baby has genetic or congenital disorders.
- D. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
Correct Answer: C
Rationale: Amniocentesis assesses for genetic disorders, not just fetal sex, and is not age-restricted or scheduled same-day without indication. Chorionic villus sampling is an alternative but not the default.
Which of the following actions should the nurse take?
- A. Place the client in a semi-Fowler's position for 1 hr after administration.
- B. Instruct the client to avoid urinary elimination until after administration.
- C. Verify that informed consent is obtained prior to administration.
- D. Allow the medication to reach room temperature prior to administration.
Correct Answer: C
Rationale: Verifying that informed consent is obtained before administering any medication or procedure is a crucial nursing responsibility. Informed consent ensures that the client is fully aware of the risks, benefits, and alternatives, and gives permission for the procedure to take place. Placing the client in a semi-Fowler's position is not necessary, as it does not enhance the medication's effectiveness. Instructing the client to avoid urinary elimination is inappropriate and could cause discomfort. Allowing the medication to reach room temperature is not required for dinoprostone inserts per standard protocols.
The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention.
- B. Petechiae.
- C. Increased muscle tone.
- D. Jitteriness.
Correct Answer: D
Rationale: Jitteriness is a common sign of hypoglycemia in newborns due to low glucose affecting neurological function. Abdominal distention, petechiae, and increased muscle tone are not typical hypoglycemia symptoms.
Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: Administering broad-spectrum antibiotics prevents infection, critical due to the risk of meningitis from leaking cerebrospinal fluid. Temperature monitoring is secondary, povidone-iodine is harmful to neural tissue, and surgery is typically within 24-48 hours.