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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 may indicate pathological conditions such as hemolytic disease or liver dysfunction. It requires immediate evaluation and treatment. Acrocyanosis (A) is a common finding in newborns due to immature circulation. Transient strabismus (B) is often seen in newborns and typically resolves on its own. Caput succedaneum (D) is swelling on the newborn's scalp from pressure during birth, which is a normal finding.
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A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider as they can indicate potential serious issues. CNS findings like altered mental status or neurological deficits may signal neurological problems. GI findings such as abdominal pain or bleeding may indicate gastrointestinal issues that require immediate attention. Respiratory findings (choice A) and oxygen saturation (choice B) are important but may not always require immediate reporting unless they are significantly abnormal. The other choices are not directly related to urgent medical concerns. Reporting CNS and GI findings ensures prompt evaluation and appropriate intervention.
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention because the client is Rh-negative and has undergone an invasive procedure that could potentially lead to mixing of maternal and fetal blood, increasing the risk of Rh sensitization. Administering Rh(0) Immune globulin helps prevent this sensitization by destroying any fetal Rh-positive red blood cells that may have entered the maternal circulation. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is relevant but not as urgent as administering Rh(0) Immune globulin. Monitoring the fetal heart rate (D) is also important, but preventing Rh sensitization takes precedence in this scenario.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 8 tablets
- B. 6 tablets
- C. 4 tablets
- D. 2 tablets
Correct Answer: C
Rationale: The correct answer is C: 4 tablets. Azithromycin 1g is equivalent to 1000mg. Since each tablet is 250mg, the nurse should administer 1000mg/250mg = 4 tablets. This dosage is appropriate for treating chlamydia infection. Choice A is incorrect because 8 tablets would be equivalent to 2000mg, which is double the prescribed dosage. Choice B is incorrect as 6 tablets would be 1500mg, which is higher than the prescribed dosage. Choice D is incorrect as 2 tablets would only be 500mg, which is lower than the prescribed dosage.