Nokea
A male neonate born at 38 weeks' gestation by cesarean delivery after prolonged rupture of the membranes and a maternal oral temperature of 102°F (38.8°C) is being observed for signs and symptoms of infection. Which of the following would alert the nurse to notify the physician?
- A. Leukocytosis.
- B. Apical heart rate of 132 bpm.
- C. Alertness changes.
- D. Warm, moist skin.
Correct Answer: A
Rationale: Leukocytosis is a sign of infection and warrants notifying the physician, especially given the maternal fever and prolonged rupture of membranes.
You may also like to solve these questions
To determine whether a primigravid client in labor with a fetus in the left occipitoanterior (LOA) position is completely dilated, the nurse performs a vaginal examination. During the examination the nurse should palpate which of the following cranial sutures?
- A. Sagittal.
- B. Lambdoidal.
- C. Coronal.
- D. Frontal.
Correct Answer: A
Rationale: In the LOA position, the fetus's occiput is anterior, and the sagittal suture (running midline along the skull) is most accessible during vaginal examination to assess dilation and fetal position. Other sutures are less prominent in this presentation.
During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
- A. Wipe off any lanolin creams from the nipple before each feeding.
- B. Position the baby with the entire areola in the baby's mouth.
- C. Feed the baby less often for the next several days.
- D. Use a mild soap while in the shower to prevent an infection.
Correct Answer: B
Rationale: Proper positioning with the areola in the baby's mouth prevents and heals sore nipples.
The nurse is caring for a multigravid client at 34 weeks' gestation diagnosed with preterm labor. The client has delivered two stillborn infants at 30 weeks' gestation. The client is scheduled for a sonogram before an amniocentesis. Which of the following would be a priority nursing diagnosis for the client?
- A. Acute pain related to abnormal uterine contractions.
- B. Anxiety related to diagnostic tests for fetal well-being.
- C. Ineffective coping related to hospitalization.
- D. Deficient knowledge related to consequences of preterm birth.
Correct Answer: B
Rationale: Anxiety related to diagnostic tests is a priority.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
While a client is being admitted to the birthing unit she states, 'My water broke last night, but my labor started two hours ago.' Which of the following is a concern? Select all that apply.
- A. Maternal lacerations.
- B. 130/80 mm Hg.
- C. Blood and mucus on perineal pad.
- D. Baseline fetal heart rate of 140 with a range between 110 and 160 with contractions.
- E. Peripad stained with green fluid.
- F. The client states, 'This baby wants out-he keeps kicking me.'
Correct Answer: E
Rationale: Prolonged rupture of membranes (>18 hours) increases infection risk, and green fluid suggests meconium, indicating potential fetal distress. Normal blood pressure, bloody show, fetal heart rate variability, and fetal movement are not immediate concerns.