Nokea
A client has postpartum psychosis. Which of the following actions is the nurse's priority?
- A. Reinforce the importance of taking antipsychotics as prescribed
- B. Ask the client if they have thoughts of harming themselves or their infant
- C. Monitor the infant for signs of failure to thrive
- D. Check the client's medical record for a history of bipolar disorder
Correct Answer: B
Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.
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A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 22/min
- B. 48/min
- C. 100/min
- D. 110/min
Correct Answer: B
Rationale: The correct answer is B: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. It is important to assess a newborn's respiratory rate to ensure proper oxygenation. Option A (22/min) is too low, while options C (100/min) and D (110/min) are too high and could indicate respiratory distress or other issues that need immediate attention. Therefore, option B falls within the expected reference range and is the correct answer for a healthy newborn assessment.
During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?
- A. Apply palms of both hands to sides of the uterus
- B. Palpate the fundus of the uterus
- C. Grasp the lower uterine segment between thumb and fingers
- D. Stand facing the client's feet with fingertips outlining cephalic prominence
Correct Answer: B
Rationale: The correct answer is option B: Palpate the fundus of the uterus. This technique helps the nurse identify the fetal lie by feeling for the position of the baby's head or buttocks at the top of the uterus. By palpating the fundus, the nurse can determine whether the baby is in a vertex (head down) or breech (head up) position. This method is effective in assessing the fetal lie as it provides direct information about the baby's orientation within the uterus.
Option A is incorrect because applying palms to the sides of the uterus does not specifically help identify the fetal lie. Option C is incorrect as grasping the lower uterine segment does not provide information on the fetal lie. Option D is incorrect because standing facing the client's feet with fingertips outlining cephalic prominence is not a technique used to determine fetal lie.
A nurse is assisting with an in-service for newly licensed nurses about neonatal abstinence syndrome in newborns. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?
- A. The newborn will have decreased muscle tone.
- B. The newborn will have a continuous high-pitched cry.
- C. The newborn will sleep for 2 to 3 hours after a feeding.
- D. The newborn will have mild tremors when disturbed.
Correct Answer: B
Rationale: The correct answer is B: The newborn will have a continuous high-pitched cry. This is indicative of neonatal abstinence syndrome (NAS) due to maternal substance use during pregnancy. The high-pitched cry is a common symptom of NAS, reflecting the newborn's central nervous system irritability. The other choices are incorrect because decreased muscle tone (Choice A) is not a typical symptom of NAS, newborns with NAS tend to have increased muscle tone; sleeping for 2 to 3 hours after a feeding (Choice C) is a normal newborn behavior and not specific to NAS; mild tremors when disturbed (Choice D) may occur but are not as characteristic of NAS as the high-pitched cry.
A client who is 2 days postpartum reports that their 4-year-old son, who was previously toilet trained, is now wetting himself frequently. Which of the following statements should the nurse provide to the client?
- A. Your son may not have been ready for toilet training and should wear training pants.
- B. Your son is displaying an adverse sibling response.
- C. Your son may benefit from counseling.
- D. Consider enrolling your son in preschool to address the behavior.
Correct Answer: B
Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately.
Incorrect choices:
A: This choice suggests the child was not ready for toilet training, which is not the primary issue here.
C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation.
D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.
A client who is postpartum has a slightly boggy and displaced fundus to the right. Which of the following actions should the nurse take based on these findings?
- A. Encourage the client to perform Kegel exercises.
- B. Encourage the client to move to the left lateral position.
- C. Ask the client to rate her pain.
- D. Assist the client to the bathroom to void.
Correct Answer: D
Rationale: The correct answer is D: Assist the client to the bathroom to void. A boggy and displaced fundus to the right in a postpartum client suggests a full bladder, which can displace the uterus. Voiding helps the uterus contract back to its normal position, reducing the risk of postpartum hemorrhage. Encouraging Kegel exercises (A) is not appropriate in this situation. Moving to the left lateral position (B) may provide temporary relief but does not address the underlying issue. Asking the client to rate her pain (C) is not relevant to the management of a displaced fundus.