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A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.
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The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
- A. Administer a PRN dose of acetaminophen.
- B. Assess perineum for excessive lochia.
- C. Document the vital signs in the record.
- D. Report heart rate to healthcare provider.
Correct Answer: C
Rationale: These vital signs are normal postpartum; documenting them ensures accurate tracking without unnecessary interventions.
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?
- A. Request placement of the epidural.
- B. Give a bolus of intravenous fluids.
- C. Decrease the oxytocin infusion rate.
- D. Determine current cervical dilation.
Correct Answer: D
Rationale: Assessing current cervical dilation ensures labor progress is suitable for epidural placement, preventing complications like slowed labor.
A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?
- A. Passive immunity in the first months of life provides protection in newborns.
- B. Infants can receive antiinfectants that have not developed resistance to microbes.
- C. Active immunity in newborns is developed fully in the first month of life.
- D. Neutrophils may be immature in protecting neonates from the risk for infection.
Correct Answer: A
Rationale: Passive immunity from maternal antibodies provides newborns with initial protection against communicable diseases, lasting several months until their immune system matures.