Nokea
A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?
- A. Evaluate the firmness of the uterus.
- B. Initiate oxygen therapy via a non-rebreather mask.
- C. Administer oxytocin infusion.
- D. Obtain a type and crossmatch.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition.
Summary:
- Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia.
- Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus.
- Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.
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A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?
- A. Maternal/newborn blood group incompatibility
- B. Absence of vitamin K
- C. Physiologic jaundice
- D. Maternal cocaine abuse
Correct Answer: A
Rationale: Step-by-step rationale for why the correct answer is A:
1. Maternal/newborn blood group incompatibility can result in hemolytic disease of the newborn.
2. Hemolytic disease causes an increase in bilirubin levels, leading to jaundice.
3. Jaundice in this case is due to the breakdown of red blood cells and elevated unconjugated bilirubin levels.
4. Physiologic jaundice is a normal process in newborns and usually appears after the first 24 hours of life.
5. Absence of vitamin K would not directly cause jaundice.
6. Maternal cocaine abuse is not typically associated with neonatal jaundice.
In summary, the correct answer is A because maternal/newborn blood group incompatibility can lead to hemolytic disease and subsequent jaundice, while the other choices are not directly related to neonatal jaundice.
A healthcare provider is assessing a newborn who has a coarctation of the aorta. Which of the following should the provider recognize as a clinical manifestation of coarctation of the aorta?
- A. Increased blood pressure in the arms with decreased blood pressure in the legs
- B. Decreased blood pressure in the arms with increased blood pressure in the legs
- C. Increased blood pressure in both the arms and the legs
- D. Decreased blood pressure in both the arms and the legs
Correct Answer: A
Rationale: The correct answer is A: Increased blood pressure in the arms with decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to increased blood pressure in the arms due to the pressure build-up before the narrowing and decreased blood pressure in the legs due to reduced blood flow beyond the narrowing. This pressure difference is a classic clinical manifestation of coarctation of the aorta.
Choices B, C, and D are incorrect because they do not align with the pathophysiology of coarctation of the aorta. B is incorrect as decreased blood pressure in the arms is not typical. C is incorrect as increased blood pressure in both the arms and legs does not reflect the characteristic pressure difference caused by the aortic narrowing. D is incorrect as decreased blood pressure in both the arms and legs is not consistent with the presentation of coarctation of the aorta.
During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?
- A. Acrocyanosis of hands and feet
- B. Anterior fontanel soft and level
- C. Plantar creases cover 2/3 of sole
- D. Vernix caseosa in inguinal creases
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
Plantar creases covering 2/3 of the sole is a standard newborn assessment finding indicating normal development. This is a key milestone in assessing the newborn's muscle tone and neurological status. Absence or presence of plantar creases can provide insights into potential developmental issues. Therefore, recording this finding is crucial for monitoring the newborn's growth and development.
Summary of Other Choices:
A: Acrocyanosis of hands and feet - Common benign finding in newborns due to immature circulation, not a specific part of newborn assessment.
B: Anterior fontanel soft and level - Important assessment, but not specific to gestational age assessment.
D: Vernix caseosa in inguinal creases - Normal finding, but not a specific part of gestational age assessment.
A healthcare provider is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider's orders. Which of the following orders requires clarification?
- A. Assess deep tendon reflexes every hour.
- B. Obtain a daily weight.
- C. Continuous fetal monitoring
- D. Ambulate twice daily
Correct Answer: D
Rationale: The correct answer is D. Ambulating a client with severe preeclampsia can be risky due to the potential for sudden worsening of symptoms and complications like seizures. It is important to prioritize rest and close monitoring in such cases. Assessing deep tendon reflexes every hour (A) is crucial as changes can indicate neurological involvement. Obtaining a daily weight (B) helps monitor fluid status. Continuous fetal monitoring (C) is necessary to assess the well-being of the fetus in cases of preeclampsia. In summary, ambulating the client with severe preeclampsia is the most concerning order as it may pose a significant risk to both the client and the fetus.
A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?
- A. These exercises facilitate preventing constipation.
- B. These exercises aid pelvic muscle stretching during birth.
- C. They assist in decreasing backaches.
- D. They can prevent additional stretch marks.
Correct Answer: B
Rationale: The correct answer is B because Kegel exercises help strengthen the pelvic floor muscles, which can aid in pelvic muscle stretching during birth. This can potentially reduce the risk of pelvic floor dysfunction postpartum.
A is incorrect because Kegel exercises do not directly prevent constipation.
C is incorrect because while Kegel exercises may indirectly help with backaches by improving pelvic floor muscle support, they are not specifically targeted for backache relief.
D is incorrect as Kegel exercises do not prevent stretch marks, as stretch marks are related to skin elasticity rather than muscle tone.