Nokea
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
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When planning for the care of an infant experiencing neonatal abstinence syndrome, which nursing assessment is most important?
- A. The mother's ability to provide a safe environment
- B. The extent of addiction of the mother
- C. The mother's ability to obtain treatment
- D. The severity of the infant's withdrawal
Correct Answer: A
Rationale: The correct answer is A: The mother's ability to provide a safe environment. This is crucial because infants with neonatal abstinence syndrome require a stable and safe environment for optimal care and recovery. Assessing the mother's ability to provide this environment helps ensure the infant's safety and well-being. Choice B is incorrect because the extent of the mother's addiction, while important, does not directly impact the immediate care of the infant. Choice C is incorrect as the focus should be on the current situation and care of the infant rather than the mother obtaining treatment. Choice D is incorrect as the severity of the infant's withdrawal, though important, is not the most critical assessment in planning care.
Which conditions create a risk for uterine atony in the immediate postpartum period?
- A. Breastfeeding and delivery of an infant with chromosome defects
- B. Postterm birth and an amniotomy during labor
- C. Gestational diabetes and pregnancy-induced hypertension
- D. Multiparity and multiple gestation
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Multiparity: Women who have had multiple pregnancies are at higher risk for uterine atony due to uterine muscle fatigue.
2. Multiple gestation: The presence of more than one fetus puts increased demands on the uterus, increasing the risk of uterine atony.
Summary of why other choices are incorrect:
- A: Breastfeeding and chromosome defects are not directly linked to uterine atony.
- B: Postterm birth and amniotomy do not inherently increase the risk of uterine atony.
- C: Gestational diabetes and pregnancy-induced hypertension are not specific risk factors for uterine atony.
Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?
- A. Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well.
- B. Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms.
- C. In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied.
- D. Using soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs.
Correct Answer: C
Rationale: The correct answer is C. It is important to stimulate adequate milk production by pumping if the infant is not sucking or eating well, or if the breasts are not fully emptied. This helps maintain milk supply and prevents engorgement. Option A is incorrect as giving a bottle of formula does not effectively relieve engorgement and can lead to decreased milk production. Option B is incorrect as applying lotion to the nipples is not necessary and may introduce harmful microorganisms. Option D is incorrect as using soap can dry the nipples and lead to cracking, and giving formula is not the recommended solution for engorgement.
A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction?
- A. Placenta previa and twins
- B. Pregnancy-induced hypertension and postterm fetus
- C. Breech position and prematurity
- D. Cephalopelvic disproportion and fetal distress
Correct Answer: B
Rationale: The correct answer is B: Pregnancy-induced hypertension and postterm fetus. Labor induction is commonly indicated in cases of pregnancy-induced hypertension to prevent complications such as preeclampsia. Postterm fetus is another common indication to prevent risks associated with a prolonged pregnancy, such as stillbirth. Placenta previa, twins, breech position, prematurity, cephalopelvic disproportion, and fetal distress are not typically primary indications for labor induction. Placenta previa may require a cesarean section, twins may be delivered vaginally or by C-section, breech position may require external cephalic version or C-section, prematurity may necessitate medical management, cephalopelvic disproportion may require a C-section, and fetal distress may necessitate immediate delivery but not necessarily labor induction.
A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers. Which of the following should the nurse include?
- A. Have syrup of ipecac available in the home.
- B. Explain to preschool children that plants can be eaten only after they are cooked.
- C. Keep labels on containers of toxic substances and never remove them.
- D. Place medications in a cabinet above the sink.
Correct Answer: C
Rationale: The correct answer is C: Keep labels on containers of toxic substances and never remove them. This is important to prevent accidental poisoning in preschoolers as it helps parents and caregivers easily identify and differentiate toxic substances from safe ones. Removing labels can lead to confusion and increase the risk of accidental ingestion. Having syrup of ipecac available (choice A) is no longer recommended as a first-aid treatment for poisoning. Teaching children to cook plants before eating them (choice B) is not a practical or safe approach. Placing medications in a cabinet above the sink (choice D) may not be effective as preschoolers can still access them if the cabinet is not securely locked.