Nokea
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis
- B. Single palmar creases
- C. Subconjunctival hemorrhage
- D. Rust-stained urine
Correct Answer: B
Rationale: The correct answer is B: Single palmar creases. This finding may indicate the presence of Down syndrome or other genetic disorders. The presence of single palmar creases warrants further evaluation by the provider to rule out any underlying conditions. Transient circumoral cyanosis, subconjunctival hemorrhage, and rust-stained urine are common and typically benign findings in newborns that do not require immediate reporting.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception.
- A. You should use an oil-based vaginal lubricant when inserting your diaphragm
- B. You should store your diaphragm in sterile water after each use
- C. You should keep the diaphragm in place for at least 4 hours after intercourse
- D. You should have your provider refit you for a new diaphragm
Correct Answer: D
Rationale: The correct answer is D: You should have your provider refit you for a new diaphragm. After childbirth, the size and shape of the cervix and vaginal canal may change, affecting the fit of the diaphragm. It is essential to have a healthcare provider assess and refit the diaphragm to ensure proper contraception.
Incorrect answers:
A: Using oil-based vaginal lubricant can degrade latex diaphragms, leading to breakage.
B: Storing the diaphragm in sterile water can damage the latex material and increase the risk of infection.
C: Keeping the diaphragm in place for a specific time after intercourse is not necessary and can increase the risk of toxic shock syndrome.
E: Not applicable.
F: Not applicable.
G: Not applicable.
A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level
Correct Answer: B
Rationale: The correct answer is B: Apply a cap to the newborn's head. This action helps prevent heat loss through the newborn's head, which is a common area for heat loss in newborns. The respiratory rate of 50/min and heart rate of 130/min are within normal ranges for a newborn. The temperature of 36.1°C (97°F) is slightly lower than the normal range, so keeping the newborn warm is important. Giving a warm bath (choice A) may further decrease the newborn's body temperature. Repositioning the newborn (choice C) may not address the issue of heat loss. Obtaining an oxygen saturation level (choice D) is not indicated based on the information provided. Therefore, applying a cap to the newborn's head is the most appropriate action to help maintain the newborn's body temperature and prevent heat loss.
A nurse is caring for a newborn boy, 6 hours old, whose bedside glucose meter reading is 65 mg/dL. The newborn's mother has Type 2 diabetes mellitus.
- A. Administer 50 mL of dextrose solution IV
- B. Obtain a blood sample of serum glucose level
- C. Reassess the blood glucose level prior to the next feeding
- D. Feed the newborn immediately
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. By feeding the newborn, the nurse can stimulate the release of insulin, which will help regulate the baby's blood sugar levels. This is important especially in the case of a newborn born to a mother with Type 2 diabetes mellitus, as the baby may be at risk for hypoglycemia. Administering IV dextrose solution (choice A) is not necessary at this point as feeding is the initial intervention. Obtaining a blood sample for serum glucose level (choice B) can be done later but immediate feeding takes precedence. Reassessing blood glucose prior to the next feeding (choice C) may delay necessary intervention.
A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
- A. Give terbutaline Subq
- B. Position the client in a knee chest position
- C. Apply oxygen via nonrebreather
- D. Administer a bolus of lactated ringer
Correct Answer: D
Rationale: The correct answer is D: Administer a bolus of lactated Ringer. Maternal hypotension following epidural placement indicates hypovolemia or vasodilation. Providing a bolus of lactated Ringer helps increase intravascular volume, improving blood pressure. Terbutaline Subq (A) is not indicated for hypotension. Positioning the client in a knee-chest position (B) is not appropriate for maternal hypotension. Applying oxygen via non-rebreather (C) may not address the underlying cause of hypotension.