Nokea
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.
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Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
- A. Document the findings in the record
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Swaddle the infant in a warm blanket
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?
- A. After ceasing breastfeeding the diaphragm should be resized.
- B. Use an alternate form of contraception until a new diaphragm is obtained.
- C. If no more than 20 pounds was gained during pregnancy, the diaphragm is safe to use.
- D. Avoid intercourse during ovulation until the size of the diaphragm has been evaluated
Correct Answer: B
Rationale: Pregnancy and childbirth can alter vaginal anatomy, making a pre-pregnancy diaphragm ineffective. An alternate contraception method is needed until a new diaphragm is fitted.
A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to
- A. dilate the pupil so the red reflex can be visualized
- B. prevent herpes infection.
- C. prevent eye infections
- D. clear the infant's vision
Correct Answer: C
Rationale: Antibiotic eye ointment, typically erythromycin, is applied to prevent neonatal conjunctivitis, particularly from gonorrhea or chlamydia, which can be transmitted during birth.
Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?
- A. Epidural block
- B. Saddle block
- C. Paracervical block.
- D. Pudendal block
Correct Answer: D
Rationale: A pudendal block targets the pudendal nerve, numbing only the vagina and perineum, making it ideal for the second stage of 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.