Nokea
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.
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A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Determine fetal position by performing Leopold maneuvers.
- B. Assess the fetal heart rate and client's contraction pattern
- C. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration
- D. Perform sterile vaginal examination to determine dilatation
Correct Answer: B
Rationale: Bright red vaginal bleeding is a critical sign that may indicate placental issues or fetal distress. Assessing the fetal heart rate and contraction pattern is the highest priority to ensure the well-being of both mother and baby.
The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?
- A. Obtain blood and urine for prenatal screens
- B. Explain common complications of pregnancy
- C. Obtain baseline blood pressure and weight
- D. Schedule prenatal visits to occur monthly
Correct Answer: A
Rationale: Given the history of syphilis, obtaining blood and urine for prenatal screens is critical to assess for active infection or other risks that could impact the pregnancy.
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.
After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
- A. Place the newborn in a position with the head lower than the feet.
- B. Turn the newborn to the side and bulb suction the mouth and nares.
- C. Wipe away the spit-up and assist the mother with the diaper change
- D. Sit the newborn upright and burp by rubbing or patting the upper back
Correct Answer: D
Rationale: Sitting the newborn upright and burping helps release trapped air, which is a common cause of spitting up after feeding.
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.