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A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
- A. Molding
- B. Vernix Caseosa
- C. Acrocyanosis
- D. Sternal retractions
Correct Answer: D
Rationale: Sternal retractions in a newborn may indicate respiratory distress or difficulty breathing. It is important for the nurse to intervene and assess the newborn's respiratory status further as this finding could be a sign of underlying respiratory issues that require immediate attention. The nurse should monitor the newborn's oxygen saturation, respiratory rate, and any other signs of distress to ensure appropriate intervention is provided promptly.
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The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate is 174 beats/minute. What is the priority nursing action?
- A. Document the finding.
- B. Check the mother's heart rate.
- C. Notify the health care provider (HCP).
- D. Tell the client that the fetal heart rate is normal.
Correct Answer: C
Rationale: A fetal heart rate above 160 bpm at term may indicate fetal distress, requiring immediate notification of the HCP.
A nurse educator is teaching a class to nursing developing cervical cancer. Which client is at students about the incidence of sexually transmitted highest risk? infections (STIs) and their impact on public health.
- A. Client with a Pap test and an HPV screen positive Which is the most commonly reported STI in the for type 12 United States?
- B. Client who is 40 years old and stopped smoking
- C. Syphilis
- D. Gonorrhea
Correct Answer: A
Rationale: Human papillomavirus (HPV) is the most commonly reported sexually transmitted infection (STI) in the United States. HPV infection, especially high-risk types such as HPV-16, is strongly associated with cervical cancer. Therefore, a client who is positive for HPV type 16 on an HPV screen is at the highest risk for developing cervical cancer among the given choices. The nurse educator would need to emphasize the importance of regular screening, follow-up, and prevention strategies for this client to reduce the risk of cervical cancer development.
A nurse is caring for a client who is in labor and requests nonpharmacological pain management. Which of the following nursing actions promotes client comfort?
- A. Assisting the client into squatting position
- B. Having the client lie in a supine position
- C. Applying fundal pressure during contractions
- D. Encouraging the client to void every 6 hr.
Correct Answer: A
Rationale: Assisting the client into a squatting position can help relieve pain and discomfort during labor. Squatting can open up the pelvis, allowing the baby to descend and progress through the birth canal more effectively. This position can also help with gravity-assisted delivery, decreasing the pressure on the mother's back and helping to reduce labor pains. Encouraging various positions during labor can provide comfort and promote optimal positioning for delivery.
LGBTQIA+ families are at higher risk for certain issues more than straight, cisgender parents. What is an example of a vulnerability experienced by LGBTQIA+ families?
- A. increased cases of social exclusion
- B. fewer cases of intimate partner violence
- C. fewer incidents of family trauma
- D. increased cases of social acceptance
Correct Answer: A
Rationale: LGBTQIA+ families often face social exclusion and discrimination, increasing their vulnerability to mental and physical health challenges.
Two hours after an epidural infusion has begun the patient complains of itching of her face and neck. The nurse should:
- A. Recognize this is a common side effect to follow protocol for administration of Benadryl
- B. Remove the epidural catheter and apply a band aid on the injection site
- C. Offer the patient a cool cloth and let her know itching is temporary
- D. Call anesthesia to remove epidural catheter
Correct Answer: A
Rationale: Itching of the face and neck following an epidural infusion is a common side effect known as pruritus. The nurse should recognize this symptom and follow the protocol for addressing itching associated with epidural infusions. In this case, administering Benadryl is a common intervention to help relieve the itching. Benadryl is an antihistamine that can help alleviate itching and discomfort without the need to remove the epidural catheter. It is important for the nurse to assess the patient's symptoms, follow proper protocols, and provide appropriate interventions to manage side effects like pruritus.