Nokea
A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct Answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences.
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Prior to an amniocentesis, what action by the client will need to be completed?
- A. Increase fluid intake
- B. Empty the bladder
- C. Avoid eating for 12 hours
- D. Take a sedative
Correct Answer: B
Rationale: Before an amniocentesis, the client should empty her bladder to reduce the risk of bladder puncture during the procedure. This is especially important in early pregnancy.
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct Answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals.
A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?
- A. Digoxin
- B. Calcium gluconate
- C. Vitamin B6
- D. Propranolol
Correct Answer: C
Rationale: Vitamin B6 (pyridoxine) is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum, and is considered safe for use in pregnant clients.
A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?
- A. Non-Hodgkin's lymphoma
- B. Endometriosis
- C. Breast cancer
- D. Polycystic ovary syndrome
Correct Answer: C
Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Other signs may include irritability and tremors.