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A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count.
- B. Increased erythrocyte sedimentation rate (ESR).
- C. Decreased megakaryocytes.
- D. Increased WBC.
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In idiopathic thrombocytopenic purpura (ITP), there is a decrease in platelet count due to immune-mediated destruction of platelets. This can lead to bleeding tendencies. Other choices are incorrect because in ITP, there is no significant change in ESR (B), megakaryocytes may be increased or normal (C), and WBC count is usually normal or slightly elevated (D).
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A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because in a nonstress test, the client is required to press a handheld button every time they feel their baby move. This action helps to monitor the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. This is essential at 37 weeks of gestation to ensure the baby is healthy and responding appropriately.
Summary of other choices:
A: Incorrect - The test duration can vary, but it typically takes longer than 10 to 15 minutes.
B: Incorrect - The client may need to change positions during the test to optimize fetal monitoring.
C: Incorrect - It is important for the client to eat and stay hydrated before the test to encourage fetal movement.
E, F, G: Choices not provided, thus irrelevant.
Exhibit1 Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth weight 3,515 g (71b 12 0z) Apgar scores 8 at 1 min and 9 at 5 min Maternal history of methadone use during
pregnancy.
Exhibit2 vital signs 0700: Heart rate 156/min Respiratory rate 58/min Temperature 37.2° C (98.9° F) Oxygen saturation 98% on room air .1100: Heart rate 160/min Respiratory rate 60/min Temperature 37.3° C (99.2° F) Oxygen saturation 96%
on room air
Exhibit3 Physical Examination 1100: Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorouslyon pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several loose stools today.Exhibit4 (image)
Apgars: 7 at 1 min and 8 at 5 min of age Birth weight: 3,515 (7 1b 12 02) Maternal blood type: O+ Uncomplicated pregnancy. Maternal use of marijuana during pregnancy Client who gave birth plans to breastfeed
A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Respiratory findings
- B. Temperature
- C. Oxygen Saturation
- D. Central nervous system findings
- E. Gastrointestinal findings
Correct Answer: A, D, E
Rationale: The correct answers are A (Respiratory findings), D (Central nervous system findings), and E (Gastrointestinal findings). These are crucial areas to monitor in a newborn to ensure their well-being. Respiratory findings are important as newborns are prone to respiratory distress. Central nervous system findings are vital for assessing neurological status. Gastrointestinal findings are necessary to monitor feeding tolerance and bowel movements. Temperature, oxygen saturation, and other choices are also important but may not be as critical in this case. It is essential to focus on the key areas that can indicate potential issues and require immediate attention.
A nurse is caring for a newborn who is 48 hr old.
Exhibit 1
Vital Signs
Day 2, 0900:
Heart rate 174/min
Respiratory rate 88/min
Temperature 36.1° C (97.0° F)
Oxygen saturation 97% on room air
Exhibit 2
Diagnostic Results
Day 1, 0800: Newborn results
Blood type: A+
Urine toxicology screen: positive marijuana
Day 2, 0800: Newborn results
Total bilirubin 10 mg/dL (1.0 to 12.0 mg/dL)
Day 2, 0915:
Blood glucose: 38 mg/dL (expected value greater than 40 to 45
gm/dL
Exhibit 3
Nurses Notes
Day 2, 0900:
Newborn awake, alert, and crying. Loosely wrapped in one
blanket. Mild tremors noted. Yellow discoloration of mucus
membranes and sclera noted. Respirations 88/min, no
retractions, grunting, or nasal flaring noted. Diaper changed for
small amount of urine and transitional stool. Exhibit 4
Medical History
Apgars: 7 at 1 min and 8 at 5 min of age
Birth weight: 3,515 g (7 lb 12 oz)
Maternal blood type: O+
Uncomplicated pregnancy. Maternal use of marijuana during
pregnancy
Client who gave birth plans to breastfeed.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
The correct answer is to place the newborn skin to skin on the birthing parent's chest and encourage breastfeeding to address Cold stress, a potential condition the client is most likely experiencing. These actions help regulate the newborn's temperature and provide essential warmth and nutrition. Parameters to monitor would include temperature (to assess for hypothermia) and bilirubin level (to monitor for jaundice, a common issue in newborns). Monitoring these parameters will help the nurse assess the client's progress and ensure appropriate interventions are implemented.