Nokea
A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. Abdominal assessment (A) is important to assess for any underlying issues. Vaginal discharge (B) could indicate infection. Temperature (D) may suggest infection or illness. Dyspareunia (E) could indicate underlying gynecological issues. Condom usage (F) is important for assessing sexual activity and risk. Heart rate (C) is a normal vital sign and doesn't necessarily require immediate reporting.
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A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This is the correct action because the steady trickle of vaginal bleeding coupled with ineffective fundal massage indicates postpartum hemorrhage, which can lead to hypovolemic shock. Administering a lactated Ringer's IV bolus helps to replace lost fluids and maintain hemodynamic stability.
Other choices are incorrect:
A: Replacing the surgical dressing does not address the underlying issue of postpartum hemorrhage.
B: Evaluating urinary output is important but not the priority when the client is experiencing postpartum hemorrhage.
C: Applying an ice pack to the incision site is not appropriate for managing postpartum hemorrhage.
Overall, in this scenario, administering IV fluids is the most critical intervention to address the potential life-threatening complication of postpartum hemorrhage.
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?
- A. Spotting
- B. Nausea
- C. Polyhydramnios
- D. Uterine tenderness
Correct Answer: A
Rationale: Spotting is a common symptom of placenta previa due to the abnormal positioning of the placenta over the cervix.
Which stage of labor is characterized by the period between the onset of regular contractions and full cervical dilation?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: A
Rationale: The correct answer is A: First stage. This stage of labor begins with the onset of regular contractions and ends with complete cervical dilation at 10 cm. During this stage, the cervix gradually thins and opens to allow the baby to pass through the birth canal. The first stage is further divided into early, active, and transition phases based on the rate of cervical dilation and effacement. The second stage (B) is characterized by the baby's descent through the birth canal and ends with the baby's delivery. The third stage (C) involves the delivery of the placenta. The fourth stage (D) is the immediate postpartum period. These stages come after the first stage of labor.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Staff wearing photo ID badges ensures proper identification for security.
2. Visual verification protects against unauthorized individuals caring for the baby.
3. ID badges indicate staff members have been vetted and authorized to care for newborns.
4. Promotes safety by ensuring only qualified individuals handle the baby.
Summary:
A: Carrying the baby to the nursery poses security risks and disrupts mother-infant bonding.
B: Documenting visitor relationships is important but does not directly address newborn security.
C: Co-sleeping with the baby in the hospital increases the risk of accidental suffocation.
D: Correct choice, as it directly addresses security and safety measures for the newborn.
E:
F:
G:
What is the primary legal responsibility of a nurse or midwife in maternal and newborn healthcare?
- A. Ensuring patient safety
- B. Maintaining patient confidentiality
- C. Providing appropriate care and treatment
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. A nurse or midwife's primary legal responsibility in maternal and newborn healthcare is to ensure patient safety by providing appropriate care and treatment while also maintaining patient confidentiality. Patient safety is paramount in healthcare to prevent harm or injury. Maintaining confidentiality is crucial to protect patient privacy and uphold ethical standards. Providing appropriate care and treatment involves assessing, planning, implementing, and evaluating care to meet the unique needs of each patient. Choosing D encompasses all these critical aspects, ensuring comprehensive legal responsibility is upheld.