Nokea
A multigravid client at 34 weeks' gestation is being treated with indomethacin(Indocin) to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following?
- A. Pulmonary hypertension.
- B. Respiratory distress syndrome(RDS).
- C. Hyperbilirubinemia.
- D. Cardiomyopathy.
Correct Answer: C
Rationale: Indomethacin can increase the risk of hyperbilirubinemia in preterm infants.
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The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.
The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results?
- A. Platelets 200,000 mm3.
- B. Lactate dehydrogenase(LDH)> 200 units/L.
- C. Uric acid 3 mg/dL.
- D. Aspartate aminotransferase(AST) 15 units/L.
Correct Answer: B
Rationale: Elevated LDH indicates possible hemolysis in HELLP syndrome.
A septic preterm neonate's I.V. was removed due to infiltration. While restarting the I.V., the nurse should carefully assess the neonate for:
- A. Fever.
- B. Hypoglycemia.
- C. Tachycardia.
Correct Answer: C
Rationale: Tachycardia can indicate pain, stress, or cardiovascular compromise during I.V. insertion, especially in a septic preterm neonate.
A nurse is discussing the contraceptive sponge with a client. Which of the following client statements indicates understanding?
- A. I need to insert the sponge at least 1 hour before intercourse.
- B. The sponge can be left in place for up to 24 hours.
- C. The sponge is more effective after childbirth.
- D. The sponge protects against HIV.
Correct Answer: B
Rationale: The contraceptive sponge can be left in place for up to 24 hours, providing flexibility. It should be inserted just before intercourse (not 1 hour prior), is less effective after childbirth, and does not protect against HIV.
The charge nurse is preparing for the day shift on the Labor and Delivery unit. Which of the following would be included in the responsibilities for this position? Select all that apply.
- A. Review the current status of each labor client with the primary nurse.
- B. Admit the new labor client sent from the triage area.
- C. Complete the work of the nurse who had to leave 30 minutes early.
- D. Follow up with the primary nurse after a delivery.
- E. Complete report of unit with the oncoming charge nurse.
Correct Answer: A,D,E
Rationale: Charge nurse responsibilities include reviewing client status, following up post-delivery, and handing off to the next charge nurse to ensure unit oversight. Admitting clients and completing another nurse's work are typically primary nurse duties.