Nokea
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus simplex
- B. Caput succedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: B
Rationale: Caput succedaneum is swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction.
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A laboring client's membranes have just ruptured. What is the nurse's next action?
- A. Assess fetal heart rate pattern
- B. Monitor uterine contractions
- C. Administer oxygen
- D. Prepare for delivery
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1° C (96.9° F)
- D. Excessive sleeping
Correct Answer: B
Rationale: Moderate tremors of the extremities are a common sign of opioid withdrawal in newborns. Other signs may include irritability, feeding difficulties, and gastrointestinal disturbances.
A nurse is caring for a client who is in the third trimester of pregnancy and has gestational diabetes. Which of the following complications is the fetus at risk for?
- A. Macrosomia
- B. Hydrocephalus
- C. Cleft palate
- D. Spina bifida
Correct Answer: A
Rationale: Gestational diabetes can result in fetal macrosomia, a condition where the baby grows larger than normal due to excess glucose in the mother's blood. This increases the risk of complications during delivery.
A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct Answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals.
A client has been prescribed raloxiphine. As the nurse, you know that raloxiphine is used to treat:
- A. Migraines
- B. Hypertension
- C. Osteoporosis
- D. Heart disease
Correct Answer: C
Rationale: Raloxiphine (Evista) is a selective estrogen receptor modulator (SERM) used primarily to prevent and treat osteoporosis in postmenopausal women. It helps to maintain bone density and reduce the risk of fractures by mimicking the effects of estrogen on bone tissue. It is not indicated for the treatment of migraines, hypertension, or heart disease.