Nokea
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, which increases the risk of postpartum hemorrhage due to the rapid dilation of the cervix. As the cervix dilates, the blood vessels in the area are more prone to bleeding post-delivery. Ectopic pregnancy (A) occurs when the fertilized egg implants outside the uterus, which is not relevant in this scenario. Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to the client's current condition. Incompetent cervix (C) is a condition where the cervix opens prematurely, typically in the second trimester, not during active labor.
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A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because newborns have sensitive skin that can easily become irritated by soaps or cleansers. Using plain water is gentle and safe for the baby's delicate skin. Additionally, washing the baby's face helps to keep the area clean and prevent any buildup of milk or debris that can lead to skin irritation or infections.
Choice A is incorrect because bathing a baby immediately after a feeding can increase the risk of spitting up or discomfort due to handling on a full stomach. Choice B is incorrect as bumper pads pose a suffocation risk for infants. Choice C is incorrect because a soft mattress can increase the risk of Sudden Infant Death Syndrome (SIDS).
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and closure. It acknowledges the baby's existence and validates the client's experience. Choice A may be incorrect as it could deprive the client of the opportunity to spend time with their baby for closure. Choice C is incorrect as it may not be necessary in all cases and could be overwhelming for the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. When a newborn is born with a nuchal cord (umbilical cord wrapped around the neck), compression can occur, leading to facial petechiae. This occurs due to the increased pressure on the blood vessels in the face during delivery. Telangiectatic nevi (A) are unrelated to nuchal cord. Periauricular papillomas (C) are benign skin lesions often found in newborns but are not specific to nuchal cord. Erythema toxicum (D) is a common benign rash in newborns, but it is not directly associated with a nuchal cord.
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct response is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically done to assess genetic abnormalities, not to determine the sex of the fetus. Amniocentesis involves obtaining a sample of amniotic fluid to analyze the fetal cells for chromosomal abnormalities like Down syndrome. The procedure is not primarily used for determining the sex of the baby. The other options are incorrect for various reasons: A is inaccurate as there is no age requirement for amniocentesis; C is incorrect as chorionic villus sampling is another prenatal diagnostic test, not typically used to determine fetal sex; and D is inappropriate as scheduling a medical procedure without further assessment is not recommended.