Nokea
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.
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Before surgery to remove an ectopic pregnancy and the fallopian tube, which of the following would alert the nurse to the possibility of tubal rupture?
- A. Amount of vaginal bleeding and discharge.
- B. Falling hematocrit and hemoglobin levels.
- C. Slow, bounding pulse rate of 80 bpm.
- D. Marked abdominal edema.
Correct Answer: B
Rationale: Falling hematocrit and hemoglobin levels indicate internal bleeding.
A client asks about the effectiveness of the contraceptive patch. Which of the following responses by the nurse is accurate?
- A. The patch is less effective than oral contraceptives.
- B. The patch is highly effective when used correctly.
- C. The patch is 100% effective in preventing pregnancy.
- D. The patch does not require a prescription.
Correct Answer: B
Rationale: The contraceptive patch is highly effective when used correctly, with a failure rate similar to oral contraceptives (about 1% with perfect use). It is not 100% effective, requires a prescription, and is not less effective than pills.
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?
- A. Relief from episiotomy pain.
- B. Contraction of the uterus.
- C. Softening of the stool.
- D. Aid in sleeping.
Correct Answer: C
Rationale: Docusate sodium is a stool softener, which helps prevent straining during bowel movements, especially important after an episiotomy.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
A primigravid client is admitted as an outpatient for an external cephalic version. The nurse should assess the client for which of the following contraindications for the procedure?
- A. Multiple gestation.
- B. Breech presentation.
- C. Maternal Rh-negative blood type.
- D. History of gestational diabetes.
Correct Answer: A
Rationale: External cephalic version (ECV) is contraindicated in multiple gestation due to the risk of cord entanglement or placental issues. Breech presentation is an indication for ECV, not a contraindication. Rh-negative blood type and gestational diabetes do not preclude ECV.