Nokea
A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?
- A. It detects Rh-positive antibodies in the mother’s blood.
- B. It determines the presence of maternal antibodies in the newborn’s blood.
- C. It detects Rh-negative antibodies in the newborn’s blood.
- D. It determines if kernicterus will occur in the newborn.
Correct Answer: A
Rationale: The correct answer is A because the indirect Coombs test detects Rh-positive antibodies in the mother's blood. In Rh incompatibility, Rh-negative mothers can develop antibodies against Rh-positive fetal blood, which can lead to hemolytic disease of the newborn. This test helps identify the presence of these antibodies to prevent harm to the newborn. Choice B is incorrect because the test is done on the mother's blood, not the newborn's. Choice C is incorrect as it refers to the wrong blood type. Choice D is incorrect as kernicterus is related to severe jaundice, not Rh incompatibility.
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A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 48/min
- B. 22/min
- C. 100/min
- D. 110/min
Correct Answer: A
Rationale: The correct answer is A: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. Choice A falls within this range, indicating a normal respiratory rate for the newborn. Choices B, C, and D are outside the expected reference range. Choice B (22/min) is too low, while choices C (100/min) and D (110/min) are too high, which could indicate respiratory distress or other underlying issues in the newborn. It is important for the nurse to monitor the newborn closely and further assess if the respiratory rate is outside the normal range.
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
- A. Ask the client if she has considered harming her newborn.
- B. Anticipate a prescription by the provider for an antidepressant.
- C. Reinforce postpartum and newborn care discharge teaching.
- D. Assist the family to identify proper use of positive coping skills in family crises.
Correct Answer: A
Rationale: The correct answer is A. The nurse should ask the client if she has considered harming her newborn as she is experiencing symptoms of postpartum depression. This is a critical step to assess the client's safety and the baby's well-being. Other choices are incorrect as B assumes the need for medication without further assessment, C focuses on teaching rather than immediate safety concerns, and D does not address the client's mental health state. By asking about harming the newborn, the nurse can assess the severity of the client's condition and provide appropriate interventions.
A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?
- A. “The cause might be too short or infrequent feedings.”
- B. “It is due to the newborn’s loss of the influence of the maternal hormones.”
- C. “This might be related to your baby having 3 stools a day.”
- D. “You might want to offer water supplements between feedings.”
Correct Answer: A
Rationale: The correct answer is A because insufficient feeding can lead to excessive weight loss in newborns. Frequent and effective breastfeeding helps ensure the baby receives enough milk and nutrients. Option B is incorrect as maternal hormones do not directly affect newborn weight loss. Option C is incorrect as the number of stools is not necessarily indicative of weight loss. Option D is incorrect as newborns should only be fed breastmilk or formula, not water supplements.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Place the client in knee-chest position.
- C. Prepare the client for an immediate birth.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord.
Correct Answer: D
Rationale: The correct answer is D: Insert a gloved hand into the vagina to relieve pressure on the cord. This is the priority action in this situation to prevent cord compression, which can compromise fetal blood flow. By gently elevating the presenting part off the cord, the nurse can help restore blood flow to the baby. Covering the cord (A) or placing the client in the knee-chest position (B) are not as effective in relieving pressure on the cord. Preparing for an immediate birth (C) may be necessary but addressing the cord issue is the priority.
A nurse is admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
- A. Administer oxygen by non-rebreather mask at 5 L/min
- B. Obtain laboratory study of prothrombin and partial thromboplastin time
- C. Methylergonovine 0.2 mg IM now
- D. Insert an indwelling urinary catheter
Correct Answer: C
Rationale: The correct answer is C: Methylergonovine 0.2 mg IM now. This prescription requires clarification because methylergonovine is a uterotonic medication that can cause severe vasoconstriction, leading to increased blood pressure. Given the client's elevated blood pressure of 146/94 mm Hg, administering methylergonovine could potentially worsen hypertension and lead to adverse effects such as stroke or myocardial infarction. It is crucial to address the high blood pressure before considering the administration of methylergonovine. The other options are not immediately concerning: A) Administering oxygen is appropriate for a client with elevated blood pressure; B) Obtaining laboratory studies is a routine part of postpartum care to assess for coagulation abnormalities; D) Inserting an indwelling urinary catheter is commonly done postpartum to monitor urinary output.