Nokea
A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
- A. Reddened with a small amount of bloody drainage.
- B. Pink without drainage.
- C. Reddened with a scant amount of yellow exudate.
- D. Reddened, with copious blood.
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound. Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications. Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
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A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Select all that apply:
- A. Antibiotic ointment to both eyes
- B. Hepatitis B immunization
- C. Lidocaine gel to the umbilical stump
- D. Haemophilus influenzae type b immunization
- E. Vitamin K injection
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A: Antibiotic ointment to both eyes is given to prevent neonatal conjunctivitis. B: Hepatitis B immunization is crucial for newborns to prevent Hepatitis B infection. E: Vitamin K injection is given to prevent hemorrhagic disease of the newborn. C: Lidocaine gel to the umbilical stump is not a standard practice and can cause local irritation. D: Haemophilus influenzae type b immunization is typically given later in infancy, not immediately after birth.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use.
- B. Blunt force trauma.
- C. Hypertension.
- D. Cigarette smoking.
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption due to the increased pressure on the placenta, leading to separation from the uterine wall. Cocaine use (A) and cigarette smoking (D) can also increase the risk but are not as common as hypertension. Blunt force trauma (B) can cause a sudden separation of the placenta but is less common compared to hypertension in a routine prenatal setting.
A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?
- A. It detects Rh-positive antibodies in the mother’s blood.
- B. It determines the presence of maternal antibodies in the newborn’s blood.
- C. It detects Rh-negative antibodies in the newborn’s blood.
- D. It determines if kernicterus will occur in the newborn.
Correct Answer: A
Rationale: The correct answer is A because the indirect Coombs test detects Rh-positive antibodies in the mother's blood. In Rh incompatibility, Rh-negative mothers can develop antibodies against Rh-positive fetal blood, which can lead to hemolytic disease of the newborn. This test helps identify the presence of these antibodies to prevent harm to the newborn. Choice B is incorrect because the test is done on the mother's blood, not the newborn's. Choice C is incorrect as it refers to the wrong blood type. Choice D is incorrect as kernicterus is related to severe jaundice, not Rh incompatibility.
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.