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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 pain and swelling, promotes healing, and improves comfort. Moist heat increases blood flow to the area, which can aid in the healing process.
Choice B: Providing a cool sitz bath may provide some relief from discomfort, but warm compresses are more effective for promoting healing in this case.
Choice C: Administering methylergonovine is not indicated for a fourth-degree perineal laceration. This medication is used to prevent or control postpartum hemorrhage.
Choice D: Applying povidone-iodine to the perineum is not recommended as it may cause irritation and delay healing.
In summary, choice A is the most appropriate action as it promotes healing and comfort for the client with a fourth-degree perineal laceration. Choices B, C, and D are not recommended in this situation.
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200Down Syndrome)
- B. Rust-stained urine
- C. Transient circumoral cyanosis
- D. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases (p200Down Syndrome). This is an important finding as it can indicate the presence of Down Syndrome in the newborn. It is important to report this to the provider promptly for further evaluation and management. Single palmar creases are not typically seen in healthy newborns.
Rust-stained urine (choice B) is likely due to urate crystals, which can be a normal finding in newborns and usually resolves on its own. Transient circumoral cyanosis (choice C) is common in newborns due to immature circulation and usually resolves without intervention. Subconjunctival hemorrhage (choice D) is also a common benign finding in newborns and usually resolves without treatment.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by symptoms such as irritability, high-pitched crying, tremors, and poor feeding due to withdrawal from substances the mother used during pregnancy. Excessive crying is a common manifestation of this syndrome. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may indicate other neurological or developmental issues.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B. Maternal cytomegalovirus can be transmitted to the newborn through saliva and urine. This is important for healthcare providers to understand as it influences infection control practices in the care of both the mother and the newborn. The other choices are incorrect because: A) Acyclovir is used to treat herpes simplex virus, not cytomegalovirus. C) Lesions are not typically visible on the mother's genitalia with cytomegalovirus. D) Airborne precautions are not required for cytomegalovirus as it is primarily transmitted through bodily fluids.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [, (0, 0, 0), (1, 0, 0), (0, 0, 1)]
Correct Answer: A, C
Rationale:
A: Inserting a large bore intravenous catheter is indicated for quick and efficient fluid administration in emergencies or critical conditions.
C: Weighing perineal pads helps monitor postpartum hemorrhage accurately by assessing the amount of blood loss.
Assessing cervical dilation (B) is not indicated unless specified for a specific medical condition. Administering methotrexate (D) is contraindicated in pregnancy and certain medical conditions.
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 action helps improve venous return to the heart, which can increase blood pressure. Placing the client on their side can prevent compression of the vena cava by the uterus, reducing hypotension. Options B and D are not directly related to managing hypotension. Option C is incorrect as massaging the fundus is typically done postpartum to prevent hemorrhage.