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A G1 P0000 gravida, whose labor was uneventful, delivered 1 minute ago. The baby’s Apgar score at this time is 3. Which of the following actions is appropriate for the nurse to make?
- A. Administer ophthalmic prophylaxis.
- B. Place the baby on the abdomen of the mother.
- C. Obtain assistance for neonatal resuscitation.
- D. Repeat the score to confirm its accuracy.
Correct Answer: C
Rationale: An Apgar score of 3 indicates the baby is in distress and requires immediate neonatal resuscitation.
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The nurse is caring for a baby whose blood type is A+ (positive) and direct Coombs’ test is + (positive), and whose mother’s blood type is O+ (positive). Which of the following nursing diagnoses is appropriate for this baby?
- A. Risk for injury to the central nervous system.
- B. Risk for fluid volume deficit.
- C. Risk for interrupted family processes.
- D. Risk for impaired parent-infant attachment.
Correct Answer: A
Rationale: A positive Coombs’ test indicates hemolytic disease of the newborn, which can lead to bilirubin buildup and potential central nervous system damage.
On the third postpartum day a client tells the nurse that she feels sad and that she cries easily. The nurse should explain about which of the following?
- A. These feelings are normal and should diminish when the baby is a week or so old.
- B. The physician will likely order an antidepressant for the client to take at home.
- C. If the client focuses on the fact that she has a healthy baby, the feelings will cease.
- D. When the client is home with her family and friends, her sad feelings will disappear.
Correct Answer: A
Rationale: Postpartum blues are common and usually resolve within a week or two. Persistent sadness may indicate postpartum depression, but initial feelings are normal.
The triage nurse is interviewing a client, 19 years old, unmarried, who states, 'I felt a hard thing on the lip of my vagina this morning. It doesn’t hurt.' Which of the following questions is most important for the nurse to ask at this time?
- A. Have any of your partners ever hurt you?'
- B. Do you ever have unprotected intercourse?'
- C. Have you ever had a baby?'
- D. Do you think you may be pregnant?'
Correct Answer: B
Rationale: Unprotected intercourse increases the risk of sexually transmitted infections (STIs), which could explain the hard lump.
The doctor has ordered a contraction stress test. The nurse should interpret which of the following as a negative test?
- A. The fetal heart remains stable in relation to 3 contractions.
- B. The uterine contractions last longer than 90 seconds.
- C. The mother reports a pain level that is less than 5 on a 10-point scale.
- D. The baby moves spontaneously 3 times in 20 minutes.
Correct Answer: A
Rationale: A negative contraction stress test indicates that the fetal heart rate remains stable during contractions, suggesting no fetal distress.
A woman asks the nurse to recommend the best douche for use after menstruation. Which of the following responses by the nurse is appropriate?
- A. Tap water with white vinegar is most refreshing and least allergenic.'
- B. It is really best for women not to douche.'
- C. Any of the over-the-counter douches is satisfactory.'
- D. It is best to douche during menstruation rather than after it is over.'
Correct Answer: B
Rationale: Douching can disrupt the natural vaginal flora and increase the risk of infections, so it is generally not recommended.