Nokea
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can present as weakness or paralysis of facial muscles. Polycythemia (A) is not typically associated with forceps-assisted births. Hypoglycemia (B) is more commonly seen in infants of diabetic mothers or preterm infants. Bronchopulmonary dysplasia (C) is a lung condition often seen in premature infants on ventilatory support. The key is to recognize the specific complications related to forceps-assisted births, making choice D the most appropriate in this scenario.
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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, leading to a foul-smelling vaginal discharge. At 20 weeks of gestation, the nurse should expect this symptom due to the infection. Thick, white vaginal discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not typically associated with trichomoniasis. Vulva lesions (choice C) are more commonly seen in herpes infection. Therefore, the malodorous discharge (choice D) aligns with the expected finding in a client with trichomoniasis at 20 weeks of gestation.
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Increased warmth in the extremity: Indicates clot progression or inflammation.
- Tachycardia: Can signify a pulmonary embolism or worsening condition.
- Leukocytosis: Suggests infection or inflammatory response.
- Scant lochia rubra: Not directly related to deep vein thrombosis, more common postpartum.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.
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: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce swelling, promote healing, and provide comfort for the client with a fourth-degree laceration. Warm compress can improve circulation and help with pain relief.
Choice B: Providing a cool sitz bath may not be ideal for promoting healing in this case as warmth is more beneficial.
Choice C: Administering methylergonovine is not appropriate for a perineal laceration and can cause unwanted side effects.
Choice D: Applying povidone-iodine after voiding can be irritating to the already sensitive area and may delay healing.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.