Nokea
A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should:
- A. Place a cold pack on the client's perineal area.
- B. Place the client in a semi-Fowler's position.
- C. Notify the client's physician immediately.
- D. Ask the client to ambulate around the room.
Correct Answer: C
Rationale: A positive Homan's sign suggests possible deep vein thrombosis, requiring immediate physician notification.
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A nurse is preparing a change-of-shift report and has been caring for a multigravid client with a normally progressing labor. Which of the following information should be part of this report? Select all that apply.
- A. Interpretation of the fetal monitor strip.
- B. Analgesia or anesthesia being used.
- C. Anticipated method of birth control.
- D. Amount of vaginal bleeding or discharge.
- E. Support persons with the client.
- F. Prior delivery history.
Correct Answer: A,B,D,E,F
Rationale: A comprehensive shift report includes fetal monitor interpretation, analgesia/anesthesia use, vaginal bleeding/discharge, support persons, and prior delivery history to ensure continuity of care. Anticipated birth control is not relevant during labor.
A viable male neonate delivered to a 28-year-old multiparous client by cesarean delivery because of placenta previa is diagnosed with respiratory distress syndrome. Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?
- A. Mother's development of placenta previa.
- B. Neonate delivered preterm.
- C. Mother receiving analgesia 4 hours before delivery.
- D. Neonate with sluggish respiratory efforts after delivery.
Correct Answer: B
Rationale: Preterm delivery is the primary risk factor for RDS due to immature lung development and insufficient surfactant production.
A newborn who is 20 hours old has a respiratory rate of 66 , is grunting when exhaling, and has occasional nasal flaring. The newborn's temperature is 98 ; he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before delivery. Based on these data, the nurse should include which of the following in the management of the infant's care?
- A. Continue recording vital signs, voiding, stooling, and eating patterns every 4 hours for 24 hours.
- B. With a health care provider (HCP) order, draw blood cultures, monitor vital signs every 2 hours as well as feeding and elimination patterns every 4 hours, newborn at bedside.
- C. Transfer the newborn to the neonatal intensive care unit with diagnosis of possible sepsis, parents at bedside.
- D. Request CBC with differential from the health care provider, keep the newborn under the radiant warmer, and monitor vital signs every 4 hours, parents at bedside.
Correct Answer: B
Rationale: The concern with this infant is sepsis based on prolonged rupture of membranes before delivery. Blood cultures would provide an accurate diagnosis of sepsis, but will take 48 hours from the time drawn. Frequent monitoring of infant vital signs, looking for changes, and maintaining contact with the parents is also part of care management while awaiting culture results.
After instruction of a primigravid client at 8 weeks' gestation diagnosed with class I heart disease about self-care during pregnancy, which of the following client statements would indicate the need for additional teaching?
- A. "I should avoid being near people who have a cold."
- B. "I may be given antibiotics during my pregnancy."
- C. "I should reduce my intake of protein in my diet."
- D. "I should limit my salt intake at meals."
Correct Answer: C
Rationale: Reducing protein intake is not recommended for clients with heart disease.
A 32-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks' gestation. She has had a prior pregnancy with pregnancy-induced hypertension. The assessments during this visit include BP 140/90, P 80, and +2 edema of the ankles and feet. Based on the client's past history and current assessment, what further information should the nurse obtain to determine if this client is becoming preeclamptic?
- A. Headaches.
- B. Blood glucose level.
- C. Proteinuria.
- D. Edema in lower extremities.
Correct Answer: C
Rationale: Proteinuria is a key indicator of preeclampsia, distinguishing it from gestational hypertension.