Nokea
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: Respiratory distress in a late preterm newborn can be a sign of hypoglycemia, as low blood sugar levels can impair respiratory function.
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What is the recommended method of pain relief during labor for a woman who wants to avoid medication and wants to move around freely?
- A. Nitrous oxide
- B. Intramuscular opioids
- C. Transcutaneous electrical nerve stimulation (TENS)
- D. All of the above
Correct Answer: A
Rationale: Nitrous oxide is a non-invasive pain relief option that allows the woman to move freely during labor.
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: Correct Answer: C - Assist the client to empty their bladder.
Rationale: The client's uterus palpated to the right above the umbilicus indicates a full bladder displacing the uterus. A distended bladder can prevent the uterus from contracting effectively, leading to increased risk of postpartum hemorrhage. Emptying the bladder helps the uterus contract properly, reducing the risk of complications. This intervention directly addresses the underlying issue.
Incorrect Choices:
A: Reassessing in 2 hours does not address the immediate concern of a full bladder causing uterine displacement.
B: Simethicone is used for gas relief and is not relevant in this situation.
D: Instructing the client to lie on their right side does not address the bladder distention issue.
E, F, G: Irrelevant as they do not address the specific problem of a full bladder causing uterine displacement.
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: Idiopathic thrombocytopenia purpura (ITP) is characterized by a decreased platelet count, which can lead to an increased risk of bleeding.
What is the recommended method of pain relief during labor for a woman who wants to avoid medication?
- A. Acupuncture
- B. Massage
- C. Water immersion
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Acupuncture, massage, and water immersion are all recommended methods for pain relief during labor for women who want to avoid medication. Acupuncture can help release endorphins, which are natural pain relievers. Massage can reduce muscle tension and promote relaxation. Water immersion, such as in a birthing pool, can provide buoyancy and comfort, easing the intensity of contractions. Each of these methods offers non-pharmacological pain relief options that can be effective during labor. Therefore, choosing all of the above options provides a comprehensive approach to managing pain without medication.
Which of the following is a potential complication of neonatal hypocalcemia?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hypotension
- D. All of the above
Correct Answer: C
Rationale: Neonatal hypocalcemia can lead to hypotension due to low calcium levels.