Nokea
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: Rationale: The correct answer is D. In the occipitoposterior position, the fetus's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can assess if the hands-and-knees position has helped relieve the pressure on the mother's sacrum, indicating effectiveness.
Incorrect Choices:
A: Suprapubic pain is not directly related to the occipitoposterior position or the hands-and-knees position.
B: Pelvic pressure may not necessarily be alleviated by changing positions in occipitoposterior position.
C: Contractions feeling further apart may not directly correlate with the effectiveness of the hands-and-knees position for back labor relief.
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A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to prevent damage to the eyes from the bright light used in phototherapy. Infants' eyes are sensitive, and prolonged exposure can lead to eye damage. Option A is incorrect as glucose water is not indicated for jaundice treatment. Option B is incorrect as turning the newborn every 4 hours is not specific to phototherapy treatment. Option C is incorrect as hydrating lotion is not necessary for phototherapy. Therefore, the crucial step of closing the newborn's eyes before applying eyepatches is essential for protecting the eyes during phototherapy.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for vegans. Vitamin B12 is primarily found in animal products, so vegans need to rely on fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and are not suitable sources for increasing intake. It is important for the nurse to recommend a specific food that is known to be fortified with vitamin B12 to meet the client's dietary needs.
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 is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
1. Increased warmth in the extremity: This is a key finding in deep vein thrombosis indicating inflammation and potential clot progression.
2. Tachycardia: Indicative of the body's response to a clot, signifying a worsening condition.
3. Leukocytosis: Elevated white blood cell count suggests an inflammatory response, further confirming a worsening condition.
Summary:
- Scant lochia rubra: Not directly related to deep vein thrombosis, less relevant in this context.
- Decreased extremity edema: While it could indicate improvement, it is not specific to deep vein thrombosis and may not be a reliable indicator.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased risk of bleeding.
D: A history of uterine atony indicates a weakened ability of the uterus to contract post-delivery, increasing the risk of hemorrhage.
B: Newborn weight is not directly related to postpartum hemorrhage risk.
E: History of human papillomavirus does not directly impact postpartum hemorrhage risk.