Nokea
A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?
- A. Intermittent abdominal pain following passage of bloody mucus.
- B. Abdominal pain with minimal red vaginal bleeding.
- C. A large amount of bright red vaginal bleeding without pain.
- D. Severe abdominal pain with increasing fundal height.
Correct Answer: C
Rationale: Placenta previa typically causes painless, bright red vaginal bleeding due to the placenta covering the cervix. Painful bleeding or increasing fundal height suggest other conditions like abruptio placentae or uterine rupture.
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A nurse is assisting in the care of a client who had a vaginal birth 2 hours ago. Which of the following actions should the nurse take?
- A. Document fundal height
- B. Observe the lochia during palpation of fundus
- C. Massage a firm fundus
- D. Determine whether the fundus is midline
- E. Administer terbutaline if the fundus is boggy
Correct Answer: A,B,D
Rationale: Documenting fundal height, observing lochia, and checking fundal position monitor uterine involution and bleeding risk. Massaging a firm fundus is unnecessary, and terbutaline is inappropriate for a boggy fundus.
A nurse is assisting in the care of a newborn who is 72 hours old and is receiving treatment for neonatal abstinence syndrome. Which of the following data collection findings should the nurse identify as requiring immediate follow-up?
- A. Blood pressure.
- B. Gastrointestinal disturbances.
- C. Skin color.
- D. NAS score.
- E. Temperature.
- F. Oxygen saturation.
- G. Central nervous system disturbances.
Correct Answer: B,D,F,G
Rationale: Gastrointestinal disturbances can cause dehydration and poor weight gain, needing urgent care. A high NAS score indicates severe withdrawal requiring immediate management. Oxygen saturation and respiratory rate are critical due to potential respiratory distress. CNS disturbances like tremors or seizures signal neurological risk needing prompt intervention.
What is a sign that a newborn may be at risk for meconium aspiration syndrome?
- A. Asymmetrical breathing
- B. Born before 38 weeks gestation
- C. Yellow-green staining on the umbilical cord
- D. Acrocyanosis
Correct Answer: C
Rationale: Yellow-green umbilical cord staining indicates meconium in amniotic fluid, a risk for aspiration. Asymmetrical breathing suggests diaphragmatic hernia, preterm birth relates to RDS, and acrocyanosis is normal.
Which of these is a characteristic of a preterm infant?
- A. Hypertonia.
- B. Long toenails.
- C. Lanugo.
- D. Dry skin.
Correct Answer: C
Rationale: Lanugo is a characteristic of preterm infants, as it is fine, downy hair covering the fetus that typically disappears by 36 weeks gestation but remains in preterm infants. Hypertonia, long toenails, and dry skin are more associated with post-term infants.
What are the signs and symptoms of Thalassemia? Select all that apply.
- A. Slow growth.
- B. Fatigue.
- C. Hematoma.
- D. Pruritus.
Correct Answer: A,B
Rationale: Slow growth and fatigue are common symptoms of thalassemia due to anemia from reduced hemoglobin production, affecting oxygen delivery and growth. Hematoma and pruritus are not typical symptoms, though bleeding risks or iron overload side effects may occur but are less direct.