Nokea
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. This is the correct intervention because a uterus palpable to the right above the umbilicus indicates a full bladder causing displacement of the uterus. Emptying the bladder will allow the uterus to return to the midline. Choice A is incorrect as the immediate issue is a full bladder, not requiring a wait of 2 hours. Choice B (administer simethicone) is incorrect as this medication is for gas relief and not relevant in this scenario. Choice D (instruct the client to lie on their right side) is incorrect as it does not address the underlying problem of a full bladder.
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A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse Include in the teaching?
- A. A nurse will draw blood from your baby's inner elbow.
- B. This test will be repeated when your baby is 2 months old.
- C. This test should be performed after your baby is 24 hours old
- D. Your baby will be given 2 ounces of water to drink prior to the test
Correct Answer: C
Rationale: Newborn genetic screening should be performed after the baby is 24 hours old to ensure accurate results. Blood is typically drawn from the heel, not the inner elbow, and no water is given prior to the test.
Which of the following is a potential cause of recurrent pregnancy loss?
- A. Chromosomal abnormalities
- B. Immunologic factors
- C. Environmental factors
- D. All of the above
Correct Answer: D
Rationale: Recurrent pregnancy loss can be caused by chromosomal abnormalities, immunologic factors, or environmental factors.
Which of the following is a potential complication of jaundice in a newborn?
- A. Kernicterus
- B. Hypoglycemia
- C. Respiratory distress
- D. Sepsis
Correct Answer: A
Rationale: The correct answer is A: Kernicterus. Kernicterus is a rare but serious complication of severe jaundice in newborns, where bilirubin levels become excessively high and cross the blood-brain barrier, leading to brain damage. Other choices are incorrect because: B) Hypoglycemia is not directly related to jaundice, C) Respiratory distress may occur but is not a direct complication of jaundice, and D) Sepsis is a separate condition from jaundice.
Which of the following is a potential complication of a postpartum hemorrhage?
- A. Hypertension
- B. Anemia
- C. Thrombocytopenia
- D. All of the above
Correct Answer: B
Rationale: The correct answer is B: Anemia. Postpartum hemorrhage can lead to excessive blood loss, causing a drop in red blood cell count and hemoglobin levels, resulting in anemia. Hypertension is not a typical complication of postpartum hemorrhage, as it is more commonly associated with conditions like preeclampsia. Thrombocytopenia, a low platelet count, may occur in severe cases of postpartum hemorrhage but is not a common complication compared to anemia. Choice D, "All of the above," is incorrect as only anemia is a direct potential complication of postpartum hemorrhage.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate energy supply to respiratory muscles. Hypertonia (choice A) is not a typical manifestation of hypoglycemia. Increased feeding (choice B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice C) is not directly related to hypoglycemia. Therefore, the most appropriate choice indicating hypoglycemia in this scenario is respiratory distress.