Nokea
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is important to prevent compression of the umbilical cord, which can lead to decreased blood flow to the fetus resulting in fetal distress or demise. By covering the protruding cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain adequate blood flow until further interventions can be performed by the healthcare team. Performing a vaginal examination by applying upward pressure on the presenting part (choice A) can further compress the cord and worsen the situation. Administering oxygen via nonrebreather mask (choice C) and initiating an infusion of IV fluids (choice D) are important interventions but should be done after addressing the umbilical cord protrusion to ensure adequate oxygenation and perfusion to the fetus.
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A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is a kidney infection commonly characterized by flank pain, which is a key symptom. Flank pain is typically located on the side of the body between the upper abdomen and the back. This pain occurs due to inflammation of the kidney tissues. The other choices are incorrect because: A) Epigastric discomfort is more indicative of issues related to the upper abdomen, such as gastritis or pancreatitis. C) A temperature of 37.7°C (99.8°F) is slightly elevated but not specific to pyelonephritis. D) Abdominal cramping is more suggestive of gastrointestinal issues like gas or constipation. Therefore, the presence of flank pain is the most relevant finding to identify pyelonephritis in a client at 30 weeks of gestation.
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D because delaying the instillation of antibiotic ophthalmic ointment can facilitate bonding between the newborn and parent, promoting skin-to-skin contact and eye contact essential for bonding. This crucial time immediately following birth sets the foundation for a strong parent-child relationship.
Summary:
A: Incorrect. Delaying antibiotic ointment instillation does not help in identifying infection manifestations.
B: Incorrect. The newborn's weight is not a factor in delaying the instillation of ointment.
C: Incorrect. The mode of delivery does not impact the timing of antibiotic ointment application.
D: Correct. Delaying ointment instillation facilitates bonding between the newborn and parent.
E, F, G: N/A
A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: "How much protein do you eat in a day?" This question is important because a vegan diet may lack sufficient protein, crucial for fetal development at 6 weeks gestation. Protein is essential for cell growth and repair. Choice B is incorrect as Vitamin C is abundant in plant-based foods. Choice C is incorrect because shellfish are not part of a vegan diet. Choice D is incorrect because consuming meat contradicts a vegan diet.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its size and well-developed muscle mass, ensuring proper absorption and minimizing the risk of injury to surrounding structures. Administering the vaccine into this muscle also helps improve vaccine efficacy. Choices B, C, and D are incorrect. Choice B, vigorously massaging the site, can cause discomfort, bruising, and potential tissue damage. Choice C, inserting the needle at a 45° angle, is not recommended for intramuscular injections as the needle should be inserted at a 90° angle to ensure proper delivery into the muscle. Choice D, using a 21-gauge needle, is not specific for newborns and can be too large for their small muscle mass, causing unnecessary pain and potential tissue damage.