Nokea
A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery?
- A. Weak, ineffective suck, and scalp edema
- B. Molding of the head and jitteriness
- C. Shrill, high pitched cry, and tachypnea
- D. Hypothermia and hemoglobin of 12.5 g/dL
Correct Answer: A
Rationale: The correct answer is A: Weak, ineffective suck, and scalp edema. Forceps delivery can cause head trauma leading to facial nerve injury, resulting in weak suck and scalp edema. Molding of the head (choice B) is a normal finding after vaginal birth. Jitteriness (choice B) may be due to immaturity rather than a complication of forceps delivery. A shrill, high-pitched cry and tachypnea (choice C) are more indicative of respiratory distress, not specific to forceps delivery. Hypothermia and hemoglobin of 12.5 g/dL (choice D) are not directly related to complications of forceps delivery.
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During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate?
- A. Hold the presenting part away from the cord
- B. Insert a scalp electrode for an internal fetal monitor
- C. Place the client in reverse Trendelenburg position
- D. Cover the cord with a dry,sterile gauze
Correct Answer: A
Rationale: The correct answer is A: Hold the presenting part away from the cord. This action helps relieve pressure on the cord, preventing further compromise of blood flow to the fetus. It is crucial to maintain fetal perfusion. Choice B (Insert a scalp electrode) and D (Cover the cord with gauze) are not appropriate as they do not address the immediate risk of cord compression. Choice C (Reverse Trendelenburg) may worsen the prolapse by shifting the presenting part higher.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms, including gastrointestinal issues like vomiting. This is due to the sudden absence of the drug after birth. Choices A, B, and C are unrelated to SSRI withdrawal. Large for gestational age is more indicative of maternal diabetes, hyperglycemia is not a typical SSRI withdrawal symptom, and bradypnea is not commonly associated with SSRI use.
Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow?
- A. Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
- B. Numerous clots are abnormal and should be reported to the physician.
- C. Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage.
- D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white.
Correct Answer: D
Rationale: The correct answer is D. Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. This is accurate information regarding the typical progression of lochia flow postpartum. Lochia rubra is the initial discharge, followed by lochia serosa, and finally, lochia alba. This teaching is important for the client to understand what to expect in terms of postpartum bleeding.
Choice A is incorrect as it inaccurately describes the color changes of lochia. Choice B is incorrect because the presence of numerous clots is common in the immediate postpartum period and not necessarily abnormal. Choice C is incorrect as perineal pad saturation is expected initially, and significant saturation may not always indicate hemorrhage.
A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan of the abdomen and tells the nurse the pain just stopped. Which of the following should the nurse do first?
- A. "The illness requires careful attention to fluid balance since hyperglycemia contributes to dehydration."'
- B. "Exercise requires additional insulin since glucose will be released from the cells during activity."'
- C. "Urine glucose must be monitored because there is a correlation between simultaneous glycosuria and blood glucose concentrations."'
- D. "The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose."'
Correct Answer: A
Rationale: The correct answer is A because in this scenario, the child's sudden relief from pain after a CT scan could indicate a possible rupture of the appendix. This is a critical situation that requires immediate attention to prevent complications such as peritonitis. Monitoring fluid balance is crucial to prevent dehydration, especially if surgery is needed. Choices B, C, and D are incorrect and not the priority as they focus on managing diabetes, which is not the primary concern in this case. Monitoring glucose levels, adjusting insulin, or modifying the diet are not immediate actions required for a child with suspected appendicitis.
A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which of the following statements made by the parents indicates a need for clarification?
- A. We keep the toilet seat down at all times.
- B. We don't answer the phone during bath time.
- C. We empty all buckets filled with water.
- D. We have our child in swimming lessons.
Correct Answer: D
Rationale: The correct answer is D because enrolling a 3-year-old child in swimming lessons does not necessarily prevent drowning incidents. It is crucial for parents to understand that even with swimming lessons, active supervision around water is essential to prevent accidents. Keeping the toilet seat down (A), avoiding distractions during bath time (B), and emptying buckets filled with water (C) are all important water safety precautions to prevent drowning incidents. Swimming lessons are beneficial, but they should not replace vigilant supervision.