Nokea
A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time?
- A. Encourage the parents to bond with their baby.
- B. Notify the neonatologist of the finding.
- C. Perform the gestational age assessment.
- D. Place the baby under the overhead warmer.
Correct Answer: A
Rationale: Bonding is encouraged during periods of reactivity.
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A client is 36 hours post-cesarean section. Which of the following assessments would indicate that the client may have a paralytic ileus?
- A. Abdominal striae.
- B. Oliguria.
- C. Omphalocele.
- D. Absent bowel sounds.
Correct Answer: D
Rationale: Absence of bowel sounds suggests ileus.
Which short-term goal is appropriate for a full-term, breastfeeding neonate?
- A. The baby will regain birth weight by 4 weeks of age.
- B. The baby will sleep through the night by 4 weeks of age.
- C. The baby will stool every 2 to 3 hours by 1 week of age.
- D. The baby will urinate 6 to 10 times per day by 1 week of age.
Correct Answer: D
Rationale: Frequent urination indicates adequate hydration.
A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman?
- A. Endometrial ischemia.
- B. Postpartum hemorrhage.
- C. Prolapsed uterus.
- D. Vaginal hematoma.
Correct Answer: B
Rationale: Abnormal placentas increase hemorrhage risk.
A woman is receiving Paxil (paroxetine) for postpartum depression. To prevent a drug/food interaction, the client must be advised to refrain from consuming which of the following?
- A. Alcohol.
- B. Grapefruit.
- C. Milk.
- D. Cabbage.
Correct Answer: B
Rationale: Grapefruit affects drug metabolism.
A nurse on the postpartum unit is caring for two postoperative cesarean clients. One client had spinal anesthesia for the delivery and the other client had an epidural. Which of the following complications will the nurse monitor the spinal client for that the epidural client is much less high risk for?
- A. Pruritus.
- B. Nausea.
- C. Postural headache.
- D. Respiratory depression.
Correct Answer: C
Rationale: Spinal anesthesia increases the risk of postural headaches.