Nokea
A newborn was transferred to the nursery 30 min after delivery. What should the nurse do first?
- A. Confirm the newborn's identification.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B because verifying the newborn's identification ensures the right baby is in the nursery. It is crucial for patient safety and prevents mix-ups. Confirming identification (choice A) is important but comes after verification. Administering vitamin K (choice C) is a necessary procedure but not the first priority. Determining obstetrical risk factors (choice D) is important but not as immediate as verifying identification. Thus, verifying the newborn's identification should be done first to prevent errors and ensure proper care.
You may also like to solve these questions
A client who is at 22 weeks of gestation reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
- A. Tell the client to follow up with a dermatologist.
- B. Explain to the client this is an expected occurrence.
- C. Instruct the client to increase her intake of vitamin D.
- D. Inform the client she might have an allergy to her skin care products.
Correct Answer: B
Rationale: The correct answer is B. The blotchy hyperpigmentation on the client's forehead is likely melasma, a common occurrence during pregnancy. This is due to hormonal changes causing increased melanin production. The nurse should educate the client that this is an expected occurrence during pregnancy and reassure her that it is usually temporary and will fade postpartum.
Choice A (Tell the client to follow up with a dermatologist) is incorrect because dermatological consultation is not typically necessary for melasma during pregnancy.
Choice C (Instruct the client to increase her intake of vitamin D) is incorrect because vitamin D deficiency is not typically associated with blotchy hyperpigmentation on the forehead during pregnancy.
Choice D (Inform the client she might have an allergy to her skin care products) is incorrect because melasma is not caused by allergies to skincare products.
A client is to receive oxytocin to augment labor. Which finding contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations
- B. Moderate variability of the FHR
- C. Cessation of uterine dilation
- D. Prolonged active phase of labor
Correct Answer: A
Rationale: The correct answer is A. Late decelerations indicate fetal distress, suggesting compromised oxygenation. Starting oxytocin can further stress the fetus, worsening decelerations. Report to prevent harm. B is incorrect as moderate variability is a reassuring sign of fetal well-being. C is incorrect as cessation of uterine dilation may indicate uterine hyperstimulation, not fetal distress. D is incorrect as prolonged active labor phase alone doesn't necessarily contraindicate oxytocin, but it may require monitoring.
A healthcare provider is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the provider expect? (Select all that apply)
- A. Chadwick's sign
- B. Goodell's sign
- C. Ballottement
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all three signs (Chadwick's sign, Goodell's sign, and Ballottement) are probable signs of pregnancy. Chadwick's sign refers to bluish discoloration of the cervix, Goodell's sign is softening of the cervix, and Ballottement is a palpable rebound of the fetus against the examiner's fingers. These signs are indicative of pregnancy and are commonly observed in pregnant individuals. Therefore, the provider should expect to see all these findings in a pregnant client. The other choices (A, B, and C) are incorrect because each of these signs individually is a probable sign of pregnancy, and the question asks for all the expected findings, not just one or two of them.
A client is reinforcing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the client include?
- A. Use a condom with sexual intercourse
- B. Avoid bubble bath solution when taking a tub bath
- C. Wipe from front to back when performing perineal hygiene
- D. Keep a daily record of fetal kick counts
Correct Answer: D
Rationale: The correct answer is D: Keep a daily record of fetal kick counts. This is important for monitoring fetal well-being, especially in cases of premature rupture of membranes. By counting fetal kicks daily, the client can assess fetal movements and report any changes promptly to healthcare providers. This helps in early detection of fetal distress or problems.
A: Using a condom with sexual intercourse is not relevant to the situation of premature rupture of membranes.
B: Avoiding bubble bath solution is important for preventing vaginal infections but not directly related to monitoring fetal well-being.
C: Wiping from front to back during perineal hygiene is a general hygiene practice and not specific to the situation of premature rupture of membranes.
When caring for clients in a prenatal clinic, a nurse should report which client's weight gain to the provider?
- A. 1.8 kg (4 lb) weight gain in the first trimester
- B. 3.6 kg (8 lb) weight gain in the first trimester
- C. 6.8 kg (15 lb) weight gain in the second trimester
- D. 11.3 kg (25 lb) weight gain in the third trimester
Correct Answer: B
Rationale: The correct answer is B: 3.6 kg (8 lb) weight gain in the first trimester. This amount of weight gain in the first trimester is higher than the recommended range of 1.1-4.5 lbs. It could indicate potential issues such as gestational diabetes or preeclampsia. Choices A, C, and D fall within or closer to the expected weight gain ranges for each trimester, making them less concerning. Reporting excessive weight gain early allows for timely intervention and monitoring.