Nokea
The nurse instructs the client to report which newborn symptom immediately?
- A. Mild jaundice on day 3
- B. Inability to suck or feed
- C. Occasional sneezing
- D. Soft spot on head
Correct Answer: B
Rationale: Inability to suck or feed is a serious symptom that may indicate neurological or health issues, requiring immediate reporting.
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The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last.
- A. The client who had a normal, spontaneous vaginal delivery 30 minutes ago.
- B. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant.
- C. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding.
- D. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control.
Correct Answer: A,D,C,B
Rationale: The client who had a normal, spontaneous vaginal delivery 30 minutes ago is priority. The first 2 hours after delivery is a time of transition, characterized by rapid changes in hemodynamic and physiological state for both the client and her newborn. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control should be assessed next. Although she is 8 hours postpartum and probably stable, she is receiving morphine, and her respiratory status should be monitored Drag and Droply. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding should be assessed next. Newborn infants should successfully breastfeed every 2—3 hours. Failing to breastfeed with adequate amount and frequency may lead to newborn complications such as excessive weight loss and jaundice. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant should be seen last; there is nothing indicating urgency.
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client’s deep tendon reflexes (DTRs), the nurse finds that they are both weak, at 1+, whereas previously they were 2+ and 3+. Which actions should the nurse plan? Select all that apply.
- A. Notify the client’s HCP about the reduced DTRs.
- B. Prepare to increase the magnesium sulfate dose.
- C. Prepare to administer calcium gluconate IV.
- D. Assess the level of consciousness and vital signs.
- E. Ask the HCP about drawing a serum calcium level.
Correct Answer: A,C,D
Rationale: The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity. Increasing the magnesium sulfate dose would worsen the situation and could lead to a depressed respiratory rate. Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate. The nurse should assess the client’s vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate. The nurse should ask the HCP about drawing a serum magnesium level (not a serum calcium level) to determine whether the client is experiencing magnesium toxicity.
The nurse is caring for the client who just gave birth. Which observation of the client should lead the nurse to be concerned about the client’s attachment to her male infant?
- A. Asking the caregiver about how to change his diaper
- B. Comparing her newborn’s nose to her brother’s nose
- C. Calling the baby “Kelly,” which was the name selected
- D. Repeatedly telling her husband that she wanted a girl
Correct Answer: D
Rationale: Seeking information about infant care is a sign that the mother is developing attachment to her infant. Pointing out family traits or characteristics seen in the newborn is a sign that the mother is developing attachment. Calling the infant by name is a sign that the mother is developing attachment to her infant. Attachment is demonstrated by expressing satisfaction with a baby’s appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up.
The 42-year-old client who had a partial hydatidiform molar pregnancy 3 months ago asks the nurse whether she and her husband can try conceiving again. Which response by the nurse is incorrect and warrants follow-up action by the observing nurse manager?
- A. “You will need serial levels of beta human chorionic gonadotropin (BHCG) drawn.”
- B. “You cannot conceive ever again because of your risk of choriocarcinoma.”
- C. “You should not become pregnant yet for 6 to 12 months.”
- D. “Your risk of another hydatidiform molar pregnancy is low.”
Correct Answer: B
Rationale: Women who have had a molar pregnancy can conceive again once their BHCG levels are normal and remain normal for a certain time period, usually 6 to 12 months. This response by the nurse is incorrect and should be followed up by the observing nurse manager. Because of the risk of choriocarcinoma, serial serum BHCG testing is completed after a hydatidiform molar pregnancy. Because the client will undergo serial serum BHCG testing after a hydatidiform molar pregnancy, she should not get pregnant for 6 to 12 months until testing is completed and it is confirmed that she does not have a malignancy. Couples with a past history of molar pregnancy have the same statistical chance of conceiving again and having a normal pregnancy as those without.
Which response by the nurse is most accurate?
- A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.
- B. Hepatitis B surface antigen (HBsAg) test can detect this defect.
- C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.
- D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.
Correct Answer: C
Rationale: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.