Nokea
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.
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A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
- A. “No, never.”
- B. “Yes, eventually.”
- C. “They will fade to silvery lines but won’t disappear completely.”
- D. “They will continue to fade and should be gone by your 6-week checkup.”
Correct Answer: C
Rationale: The correct answer is C: “They will fade to silvery lines but won’t disappear completely.” This response is the best because it provides a realistic expectation to the patient. Stretch marks may lighten over time but typically do not completely disappear. Choice A is incorrect as it provides a definitive and discouraging answer. Choice B is vague and does not offer a clear timeframe. Choice D is incorrect as it gives an overly optimistic timeline that may not be realistic for most individuals. Overall, choice C is the most accurate and supportive response for the patient's query.
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved?
- A. Moderate lochia flow.
- B. Decreased pain level.
- C. Stable blood pressure.
- D. Fundus above the umbilicus.
Correct Answer: A
Rationale: Improved lochia flow indicates resolution of atony.
A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time?
- A. Remind the mother that she will be able to have another baby in the future.
- B. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket.
- C. Ask the woman if she would like the doctor to prescribe a sedative for her.
- D. Remove the baby from the delivery room as quickly as possible.
Correct Answer: B
Rationale: Providing dignity to the baby is important.
A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?
- A. The baby does rarely open his mouth but you can see that he isn't in any distress.
- B. Babies usually breathe in and out through their noses so they can feed without choking.
- C. Everything about babies is small. It truly is amazing how everything works so well.
- D. You are right. I will report the baby's small nasal openings to the pediatrician right away.
Correct Answer: B
Rationale: Nasal breathing is normal in newborns to allow simultaneous feeding and breathing.
To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body?
- A. Feet.
- B. Hands.
- C. Back.
- D. Mouth.
Correct Answer: D
Rationale: Epstein's pearls are small white nodules found on the gums or palate.