Nokea
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns, the lack of muscle tone results in minimal arm recoil, which is a characteristic finding in the New Ballard Score for assessing gestational age. This is due to the immaturity of the neuromuscular system in premature infants. Choice B, popliteal angle of 90°, is incorrect as flexion of the hips and knees is more common in preterm infants. Choice C, creases over the entire foot sole, is incorrect as full development of foot sole creases is seen in term infants. Choice D, raised areolas with 3 to 4 mm buds, is incorrect as these are signs of breast development and are not specific to gestational age assessment.
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A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This helps to improve blood flow and circulation, which can help increase blood pressure in a hypotensive client. Placing the client on their side also helps prevent potential complications such as supine hypotension syndrome.
Choice B is incorrect because administering oxygen may not directly address the underlying cause of hypotension in this situation.
Choice C is incorrect as massaging the fundus is typically done to assess postpartum bleeding in women who have recently given birth, not for hypotension following epidural anesthesia.
Choice D is incorrect because while emptying the bladder can help in some cases of hypotension, it may not be the most immediate or appropriate action in this scenario.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: The correct answer is C: Anticipate a prescription for misoprostol. Misoprostol is a medication used to help contract the uterus and control postpartum hemorrhage caused by uterine atony. It helps stimulate uterine contractions and reduce bleeding. Administering betamethasone (choice A) is not indicated for uterine atony and postpartum hemorrhage. Avoiding sterile vaginal examinations (choice B) does not address the underlying issue of uterine atony. Obtaining a specimen for a Kleihauer-Betke test (choice D) is used to assess the amount of fetal-maternal hemorrhage and is not an immediate intervention for uterine atony.
What is the recommended method of administering vitamin K to a newborn who is at risk for bleeding?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: A
Rationale: The correct answer is A: Intramuscular injection. This method ensures rapid and complete absorption, providing immediate protection against bleeding in newborns. Oral administration may be ineffective due to immature gastrointestinal tract. Topical application may not achieve adequate absorption. Subcutaneous injection may lead to variable absorption rates, delaying the onset of vitamin K's protective effects. Thus, intramuscular injection is the most reliable and recommended method for newborns at risk for bleeding.
Which of the following is a potential complication of a cesarean delivery?
- A. Postpartum hemorrhage
- B. Infection
- C. Deep vein thrombosis (DVT)
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Postpartum hemorrhage can occur due to surgical trauma, infection can develop at the incision site, and deep vein thrombosis (DVT) can result from immobility post-surgery. Choosing A, B, or C alone would be incorrect as cesarean delivery carries risks of all these complications. Selecting E, F, or G is incorrect due to lack of relevance to cesarean delivery complications.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because obtaining informed consent ensures that the client understands the risks, benefits, and alternatives of the procedure. It also respects the client's autonomy and right to make decisions about their care.
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could potentially harm the client by causing urinary retention.
Summary: The correct action is to ensure informed consent is obtained, as it is a fundamental ethical and legal requirement in healthcare.