Nokea
A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
- A. Two veins and one artery
- B. One artery and one vein
- C. Two arteries and one veins
Correct Answer: C
Rationale: The correct answer is C: Two arteries and one vein. The umbilical cord typically contains two arteries (carrying deoxygenated blood from the fetus to the placenta) and one vein (carrying oxygenated blood from the placenta to the fetus). This is known as the "AVA" pattern. This configuration is essential for fetal circulation and oxygenation. Option A is incorrect as it has two veins and one artery, which is not the norm. Option B is also incorrect as it has one artery and one vein, missing one artery. Option D is incomplete, so it is also incorrect. Ultimately, the presence of two arteries and one vein in the umbilical cord is the correct and expected vascular arrangement for fetal circulation.
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The nurse is preparing a client for cesarean delivery. What is the priority nursing action before surgery?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Administer prophylactic antibiotics.
- D. Verify signed informed consent.
Correct Answer: D
Rationale: The correct answer is D, verifying signed informed consent. This is the priority because it ensures the client's understanding and agreement to the procedure, respecting their autonomy. Obtaining baseline vital signs (A) is important but not the priority before surgery. Inserting a urinary catheter (B) may be needed but is not the priority over informed consent. Administering antibiotics (C) is important for preventing infection but should not take precedence over confirming the client's informed consent.
The nurse is preparing a client for induction of labor. What is the purpose of administering oxytocin?
- A. Stimulate uterine contractions.
- B. Relieve pain during labor.
- C. Promote cervical ripening.
- D. Reduce maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Stimulate uterine contractions. Oxytocin is administered to induce labor by increasing the frequency and strength of uterine contractions. This helps progress labor and facilitate delivery. Choice B is incorrect as pain relief is usually achieved through analgesics or anesthesia. Choice C is incorrect because cervical ripening is typically promoted with medications like prostaglandins. Choice D is also incorrect as oxytocin can actually cause a temporary increase in blood pressure.
A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: The correct answer is C because the spot of blood on the diaper of a 4-day old female newborn is a normal finding due to the withdrawal of maternal hormones. During pregnancy, the baby is exposed to maternal hormones, and after birth, the sudden decrease in these hormones can cause a temporary withdrawal bleeding. This is known as pseudomenstruation and is common in newborn girls. It is important for the nurse to reassure the mother that this is a normal and harmless occurrence.
Choice A is incorrect because urinary infection is not typically the cause of blood on the diaper in a newborn. Choice B is incorrect because jaundice does not typically present with blood in the diaper. Choice D is incorrect because while breastfeeding is important for the baby's immune system, it is not directly related to the presence of blood on the diaper in this case.
A newborn is suspected of having substance abuse instructions? exposure. Which of the following assessment findings
- A. Exercise will decrease my metabolism and should the nurse expect? Select all that apply.
- B. Increased weight gain
- C. Starting on Glucophage will take the place of
- D. Seizures
Correct Answer: D
Rationale: The correct answer is D: Seizures. Substance abuse exposure in a newborn can lead to withdrawal symptoms, including seizures. This is because the newborn's central nervous system may have been affected by the substances. Seizures are a serious medical emergency and require immediate attention.
Explanation for why other choices are incorrect:
A: Exercise and metabolism are not directly related to substance abuse exposure in a newborn.
B: Increased weight gain is not a typical assessment finding for newborns with substance abuse exposure.
C: Glucophage is a medication used to treat diabetes, and it does not relate to substance abuse exposure in a newborn.
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are hard and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. The client is exhibiting early indications of mastitis.
- B. Additional interventions are not indicated at this time.
- C. Application of a heating pad to the breasts is indicated.
- D. The client should be advised to remove her nursing bra.
Correct Answer: B
Rationale: Correct Answer: B - Additional interventions are not indicated at this time.
Rationale:
1. Fundus location: Three fingerbreadths below the umbilicus is within normal range for 3 days postpartum.
2. Lochia rubra: Moderate lochia rubra is expected at this stage postpartum.
3. Breasts: Hard and warm breasts are indicative of engorgement, a common issue in breastfeeding mothers.
Summary:
A: Early indications of mastitis would include redness, warmth, and tenderness in the breasts, along with flu-like symptoms.
C: Application of a heating pad to the breasts can worsen engorgement and increase the risk of mastitis.
D: Removing a nursing bra may offer some relief for engorgement, but it is not the priority intervention at this time.