Nokea
A nurse is assessing a full-term newborn arm admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis - i think this is referring to acrocyanosis which is normal
- B. Single Palmar creases - down syndrome - p.27
- C. Subconjunctival hemorrhage - expected
- D. Rust stain urine - expected
Correct Answer: B
Rationale: The correct answer is B: Single Palmar creases - down syndrome. This finding should be reported to the provider because it is a physical characteristic associated with Down syndrome. The presence of a single palmar crease can indicate a chromosomal abnormality and requires further evaluation.
A: Transient circumoral cyanosis is a common finding in newborns and is typically related to acrocyanosis, which is considered normal in the immediate postnatal period.
C: Subconjunctival hemorrhage is a common occurrence during the birth process and is often benign, resolving on its own without intervention.
D: Rust stain urine may be a result of uric acid crystals and is considered expected in newborns due to the metabolism of fetal hemoglobin. It does not typically require immediate reporting to the provider.
In summary, the other choices are considered normal or expected in newborns, while the presence of a single palmar crease requires further assessment due to its association with Down syndrome.
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A nurse is caring for four enter-partum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client at 32 weeks of gestation reporting seeing floating spots first because it could indicate a serious condition called preeclampsia, characterized by high blood pressure and organ damage. This client's symptom is a sign of visual disturbances, a classic symptom of preeclampsia. Immediate assessment is necessary to prevent complications such as seizures and stroke. The other clients' symptoms, urinary frequency, leg cramps, and periodic numbness in fingers, are common discomforts in pregnancy but do not suggest immediate serious complications like preeclampsia.
A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique. Which of the following? - p170-171 - postprocedure bottom of 170 and goes into top of 171.
- A. The plastibell will be removed 4 hours after the procedure
- B. Notify the provider is the end of your penis appears dark red
- C. Make sure the newborn's diaper is snug
- D. Yellow exudate will form at the surgical site in 24 hours
Correct Answer: D
Rationale: The correct answer is D. Yellow exudate forming at the surgical site in 24 hours is expected after plastibell circumcision due to the healing process. This exudate consists of dead cells and is a normal part of wound healing. It is important for the parents to be aware of this so they do not mistake it for an infection or abnormality.
Explanation for other choices:
A: The plastibell is not removed after 4 hours; it falls off on its own in about 5-10 days.
B: Dark red appearance at the end of the penis could indicate a potential issue, but immediate notification of the provider is not necessary.
C: Ensuring the newborn's diaper is snug is unrelated to the circumcision technique.
E, F, G: No information provided.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous from pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because applying steady pressure with a tennis ball to the lower back can help relieve lower back pain during labor. This technique targets the sacral area, which can alleviate discomfort and provide comfort. Choice A is incorrect as upward pressure on the lower abdomen may not be effective for pain relief. Choice B is incorrect as applying continuous pressure between the thumb and index finger is not related to counter pressure for labor pain. Choice C is incorrect as pressure on the top of the uterus during contractions is not a recommended technique.
A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
- A. Initiate an infusion of IV fluids for the client
- B. Perform vaginal examination by applying upward pressure on the presenting part
- C. Administer oxygen via non rebreather mask at 8L/ min. D. Cover the umbilical cord with sterile saline saturated towel.
- D. Cover the umbilical cord with sterile saline saturated towel.
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This is the correct next step because it helps prevent compression of the cord, which could lead to fetal compromise. By covering the cord with a sterile saline towel, the nurse can protect it from drying out and maintain a moist environment. This step is crucial in preventing further harm to the fetus.
A: Initiate an infusion of IV fluids for the client - This is not the priority at this moment. The focus should be on managing the umbilical cord prolapse and fetal distress.
B: Perform vaginal examination by applying upward pressure on the presenting part - This action could potentially worsen the situation by further compressing the cord. It is not recommended in this scenario.
C: Administer oxygen via non-rebreather mask at 8L/min - While oxygenation is important for the client and fetus, managing the umbilical cord prolapse takes precedence in this situation.
In summary, covering
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1 hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1 hour glucose tolerance test. At 24-week prenatal appointment, screening for gestational diabetes is crucial. This test helps identify any glucose intolerance in pregnant women. The other choices are incorrect because: B: Rubella titer is typically done earlier in pregnancy to assess immunity. C: Group B strep culture is usually done around 35-37 weeks to determine if the mother needs antibiotics during labor. D: Blood type and Rh testing are important but are usually done earlier in pregnancy to determine if the mother is Rh negative and needs Rhogam.