Nokea
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 of life can be indicative of pathological conditions such as hemolytic disease or liver dysfunction. The nurse should report this to the provider promptly for further evaluation and management. Acrocyanosis (A) and caput succedaneum (D) are common and normal findings in newborns. Transient strabismus (B) is also common and typically resolves on its own. Make sure to assess for any other concerning symptoms and report them as well.
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A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can potentially worsen the injury and increase the risk of infection. The suppository insertion may cause trauma to the already compromised tissue, leading to further complications. It is crucial to avoid any interventions that can exacerbate the injury and hinder the healing process. Choices A, B, and C are not contraindications to using a suppository. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of using a suppository in this scenario.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: Correct Answer: A. Apply a moist, warm compress to the perineum.
Rationale: Applying a moist, warm compress helps reduce pain, swelling, and discomfort in the perineal area postpartum. It promotes healing and provides comfort to the client with a fourth-degree laceration. This action also helps improve circulation to the area, aiding in the healing process.
Incorrect Choices:
B: Providing a cool sitz bath may provide relief for hemorrhoids or perineal discomfort but is not the best option for a fourth-degree laceration. Warm compresses are more suitable in this situation.
C: Administering methylergonovine is used to prevent or treat postpartum hemorrhage, not for perineal lacerations.
D: Applying povidone-iodine after voiding is not recommended as it can be irritating to the wound and delay healing.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding may indicate a serious condition called preeclampsia, characterized by high blood pressure and protein in the urine, posing risks to both the mother and baby. Reporting this promptly allows for timely management and monitoring.
Incorrect choices:
B: Varicose veins in the calves are common in pregnancy due to increased blood volume and pressure on veins, usually not an urgent concern.
C: Nonpitting 1+ ankle edema is a mild swelling often seen in pregnancy, which is typically expected and not alarming at this stage.
D: Hyperpigmentation of the cheeks, known as melasma or "mask of pregnancy," is a common cosmetic change in pregnancy, not requiring immediate medical attention.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D, malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, resulting in a foul-smelling, frothy, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis and is often accompanied by vaginal itching and discomfort. Thick, white discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not a typical symptom of trichomoniasis. Vulva lesions (choice C) are more commonly associated with herpes or syphilis. Therefore, based on the client's gestational age and diagnosis, malodorous discharge is the most likely finding.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. This is because cytomegalovirus (CMV) is commonly spread through bodily fluids like saliva, urine, and breast milk. It is important for the nurse manager to emphasize this point to the newly licensed nurses to highlight the potential routes of transmission.
Choice A is incorrect because acyclovir is not used for the treatment of CMV; it is used for herpes simplex virus infections. Choice C is incorrect because CMV typically does not present with visible lesions on the mother's genitalia. Choice D is incorrect because CMV is not transmitted through airborne routes, so airborne precautions are not necessary. It is important to focus on educating about the correct modes of transmission to prevent the spread of CMV.