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Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.
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A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn may indicate respiratory distress, which requires immediate attention from the provider to prevent further complications. Acrocyanosis (choice B) is a common finding in newborns and is considered normal. Overlapping suture lines (choice C) can be a result of molding during the birth process and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) falls within the normal range for a newborn and does not require immediate reporting.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of a serious issue such as respiratory distress syndrome. This finding requires immediate attention from the provider to assess and manage the newborn's respiratory status. Acrocyanosis (B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (C) can be normal in newborns due to molding during birth. A head circumference of 33 cm (13 in) (D) falls within the normal range for a newborn and does not require immediate reporting.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates a lack of uterine tone, which can lead to postpartum hemorrhage. Administering oxytocin helps to stimulate contractions, restoring uterine tone and reducing bleeding. Excess vaginal bleeding is also an indication for oxytocin as it helps to control bleeding by promoting uterine contractions. Choices B, D, and the remaining options do not directly relate to the need for oxytocin administration in postpartum care. A cervical laceration would require appropriate wound management, and increased afterbirth cramping may not necessarily warrant oxytocin administration unless coupled with other signs of uterine atony.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on skeletal muscle and cardiac function. It is essential to have calcium gluconate readily available in case of magnesium toxicity.
Incorrect Choices:
A: Restricting hourly fluid intake is not necessary for a client with preeclampsia receiving magnesium sulfate IV.
C: Assessing deep tendon reflexes every 6 hours is not the most critical action to take to prevent or manage magnesium toxicity.
D: Monitoring intake and output every 4 hours is important for overall client assessment but is not directly related to managing magnesium toxicity in this scenario.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring at 38 weeks of gestation, the nurse should perform Leopold maneuvers to determine the position of the fetus, fetal lie, presentation, and engagement. This helps in locating the fetal back and identifying the optimal placement for the transducer. Progression of dilatation and effacement (choice A) is more relevant for labor assessment. Completing a sterile speculum exam (choice C) is not necessary for fetal monitoring. Preparing a Nitrazine paper test (choice D) is used to assess for rupture of membranes, not for applying an external transducer.