Nokea
A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some 'heart damage.' The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
- A. Sleep deprivation.
- B. Fluid volume excess
- C. Nausea and vomiting
- D. Risk for infection.
Correct Answer: B
Rationale: Heart damage from rheumatic fever increases the risk of heart failure, particularly postpartum due to fluid shifts. Managing fluid volume excess is the priority.
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During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Use a fingertip to palpate the inguinal canal for a weakening or indentation
- B. Measure the size of the scrotal sac for length and width.
- C. Perform transillumination of the scrotal sac to visualize shadows of the testes
- D. Observe the urethral opening on the surface of the penis when the newborn voids
Correct Answer: A
Rationale: Palpating the inguinal canal is the next step to check for undescended testes, which may be located in the inguinal area.
A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema
- B. Ascertain the frequency of headaches
- C. Evaluate for history of cluster headaches
- D. Observe and time client's contractions
Correct Answer: A
Rationale: Elevated blood pressure at 32 weeks may suggest preeclampsia. Inspecting for facial edema is a priority to assess for fluid retention, a key sign of this condition.
The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?
- A. Request a return demonstration of a diaper change
- B. Evaluate infant feeding techniques prior to discharge
- C. Provide the results of the infant's hearing test to the parents.
- D. Ensure that they have the pediatric clinic's phone number
Correct Answer: B
Rationale: Proper feeding techniques are critical for the infant's nutrition and growth, making evaluation of these skills the priority before discharge.
A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?
- A. Estimated amount of fluid.
- B. Color and consistency of fluid.
- C. Time the membranes ruptured
- D. Any odor noted when membranes ruptured
Correct Answer: C
Rationale: The time of membrane rupture is critical to assess the risk of infection, which increases with prolonged rupture, especially in active labor.
The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
- A. Explain reasons consent for an infant autopsy is needed
- B. Determine if the mother desires a visit from her clergy
- C. Encourage the mother to hold and spend time with her baby
- D. Create a memory box of baby's footprints and photographs
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.