Nokea
A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the following assessment findings. Which of the findings should the nurse report to the primary health care provider? Select all that apply.
- A. Harlequin sign.
- B. Extension of the toes when the lateral aspect of the sole is stroked.
- C. Elbow moves past the midline when the scarf sign is assessed.
- D. Slightly curved pinnae of the ears that are slow to recoil.
Correct Answer: A
Rationale: Harlequin sign indicates vascular compromise.
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The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug?
- A. Monitor the urinary output hourly.
- B. Supervise while the woman holds her newborn.
- C. Position the woman slightly elevated on her left side.
- D. Ask any visitors to leave the room.
Correct Answer: B
Rationale: Supervision ensures safety due to potential sedation.
Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
- A. Pain level 5 on scale of 0 to 10
- B. Saturated pad over a 2-hour period
- C. Urinary output of 500 mL in one voiding
- D. Uterine fundus 2 cm above the umbilicus
Correct Answer: B
Rationale: The correct answer is B because a saturated pad over a 2-hour period 24 hours after vaginal birth could indicate postpartum hemorrhage, a serious complication requiring immediate intervention. Excessive bleeding can lead to hypovolemic shock and endanger the mother's life. Monitoring and managing postpartum bleeding is crucial to prevent complications.
A: Pain level of 5 is subjective and may vary among individuals. It does not necessarily indicate a need for immediate intervention.
C: Urinary output of 500 mL in one voiding is within the normal range for postpartum women and does not suggest an immediate need for intervention.
D: Uterine fundus 2 cm above the umbilicus is within the expected range for 24 hours postpartum and does not indicate a need for immediate intervention.
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
- A. Fever.
- B. Flank pain.
- C. Dark-colored urine.
- D. Swelling at the injection site.
Correct Answer: D
Rationale: Localized swelling and dark urine may occur.
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
- A. Pain.
- B. Bleeding.
- C. Warmth.
- D. Redness.
Correct Answer: A
Rationale: Pain is a common symptom of a vaginal hematoma.
Which patient is more likely to have less stress adjusting to her role as a mother?
- A. A 26-year-old woman who is returning to work in 10 weeks
- B. A 35-year-old anxious mother who has had no contact with babies or children
- C. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother
- D. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth
Correct Answer: A
Rationale: The correct answer is A because the 26-year-old woman who is returning to work in 10 weeks is more likely to have less stress adjusting to her role as a mother. This is because she is likely more established in her career, which can provide a sense of stability and financial security. Additionally, knowing she will return to work in 10 weeks can give her a sense of structure and purpose, reducing uncertainty and stress.
Choice B is incorrect because the 35-year-old anxious mother who has had no contact with babies or children may struggle with feelings of inadequacy and anxiety due to lack of experience with children.
Choice C is incorrect because the 16-year-old teenager living with strained relationship with her mother may face additional stressors from family dynamics and lack of maturity.
Choice D is incorrect because the 25-year-old woman who knew early in her pregnancy and delivered twins by cesarean birth may face physical challenges and increased demands of caring for twins, leading to higher stress levels.