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 newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight should be classified as which of the following?
- A. Low birth weight
- B. Appropriate for gestational age
- C. Small for gestational age
- D. Large for gestational age
Correct Answer: B
Rationale: The correct answer is B: Appropriate for gestational age. A newborn is considered appropriate for gestational age when their weight falls within the 10th to 90th percentiles for their gestational age. In this case, the newborn is in the 60th percentile for weight, indicating that the weight is appropriate for the gestational age of 38 weeks.
Choice A: Low birth weight is incorrect because a newborn is classified as low birth weight when their weight is below 2,500 g regardless of gestational age.
Choice C: Small for gestational age is incorrect because a newborn is classified as small for gestational age when their weight is below the 10th percentile for their gestational age.
Choice D: Large for gestational age is incorrect because a newborn is classified as large for gestational age when their weight is above the 90th percentile for their gestational age.
A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?
- A. Apply cold compresses to the affected extremity
- B. Massage the affected extremity
- C. Allow the client to ambulate
- D. Measure leg circumferences
Correct Answer: D
Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.
A healthcare provider is assisting with the care of a newborn immediately following birth. Which of the following nursing interventions is the highest priority?
- A. Initiating breastfeeding
- B. Performing the initial bath
- C. Giving a vitamin K injection
- D. Covering the newborn's head with a cap
Correct Answer: D
Rationale: The correct answer is D: Covering the newborn's head with a cap. This is the highest priority as newborns are at risk for heat loss due to their large head surface area. By covering the newborn's head with a cap, heat loss can be minimized, helping to maintain the baby's body temperature. This is crucial for the newborn's overall well-being and to prevent complications such as hypothermia.
Initiating breastfeeding (A) is important for newborn nutrition but can be delayed slightly without immediate harm. Performing the initial bath (B) can also wait as it is not as urgent as maintaining the newborn's temperature. Giving a vitamin K injection (C) is important for blood clotting but can be done after ensuring the baby's temperature is stable.
During an assessment, a healthcare provider observes small pearly white nodules on the roof of a newborn's mouth. This finding is a characteristic of which of the following conditions?
- A. Mongolian spots
- B. Milia spots
- C. Erythema toxicum
- D. Epstein's pearls
Correct Answer: D
Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment.
A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth.
B: Milia spots are small, white, raised bumps on the skin, not found in the mouth.
C: Erythema toxicum is a common benign rash in newborns, not related to the mouth.
In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.
When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?
- A. Babinski
- B. Rooting
- C. Moro
- D. Stepping
Correct Answer: B
Rationale: The correct answer is B: Rooting. This reflex helps the newborn turn their head towards a stimulus, such as the mother's nipple, facilitating latching during breastfeeding. Babinski (A) is a reflex related to the sole of the foot, Moro (C) is a startle reflex, and Stepping (D) involves movements resembling walking. These reflexes do not directly support the latch during breastfeeding. Rooting reflex is the most relevant and essential reflex for successful breastfeeding initiation.