Nokea
A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply.
- A. Look up the client's blood type in the chart.
- B. Check the client's arm bracelet.
- C. Check the blood type on the infusion bag.
- D. Obtain an infusion bag of dextrose and water.
Correct Answer: B
Rationale: Blood type verification is critical.
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A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner?
- A. Foul-smelling lochia.
- B. Engorged breasts.
- C. Cracked nipples.
- D. Cluster of hemorrhoids.
Correct Answer: A
Rationale: Foul-smelling lochia indicates infection.
The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse’s priority action related to this finding?
- A. Inform the health care provider.
- B. Encourage the patient to urinat
- C. Massage the uterus to expel clots.
- D. Document the finding in the patient’s chart.
Correct Answer: D
Rationale: The correct answer is D: Document the finding in the patient’s chart. The fundus being firm and at the umbilicus indicates normal involution after delivery. Documenting this finding is essential for accurate assessment and continuity of care. Informing the health care provider (choice A) is not necessary as the finding is normal. Encouraging the patient to urinate (choice B) is important for postpartum care but not the priority in this situation. Massaging the uterus to expel clots (choice C) is not indicated as the fundus is already firm, indicating proper contraction.
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
- A. The eyes cross and uncross when they are open.
- B. The ears are positioned in alignment with the inner and outer canthus of the eyes.
- C. Axillae and femoral folds of the baby are covered with a white cheesy substance.
- D. The nostrils flare whenever the baby inhales.
Correct Answer: D
Rationale: Nostril flaring indicates respiratory distress.
A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first?
- A. Give two breaths.
- B. Discontinue medications.
- C. Call a code.
- D. Check carotid pulse.
Correct Answer: A
Rationale: Immediate ventilation is critical.
A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
- A. Place a pillow in her lap.
- B. Position the head of the baby in her elbow.
- C. Put the baby on his back.
- D. Move the breast toward the mouth of the baby.
Correct Answer: A
Rationale: A pillow supports the baby and reduces strain.