Nokea
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Prepare the newborn for transport to the NICU.
- B. Call the provider to further assess the newborn.
- C. Ask another nurse to verify the heart rate.
- D. Document this as an expected finding.
Correct Answer: D
Rationale: The correct answer is D: Document this as an expected finding. In a newborn, a heart rate of 130/min is within the normal range (120-160/min). The nurse does not need to take any immediate action as this heart rate is considered normal for a newborn. Documenting this finding is important for ongoing assessment and continuity of care.
Choice A is incorrect because there is no indication for transport to the NICU based solely on the heart rate. Choice B is unnecessary as further assessment is not warranted for a normal heart rate. Choice C is not needed as the nurse is capable of accurately assessing the heart rate.
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A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. Additional interventions not indicated at this time.
- B. Application of a heating pad to the breasts is indicated.
- C. The client should be advised to remove her nursing bra.
- D. The client is exhibiting early indications of mastitis.
Correct Answer: A
Rationale: Rationale: The nurse should interpret the findings as normal for a client 3 days postpartum. The fundus being 3 fingerbreadths below the umbilicus is within the expected range. Moderate lochia rubra is normal postpartum bleeding. Full and warm breasts are expected signs of lactation. Choice A is correct because the findings do not indicate any complications requiring additional interventions at this time. Choices B and C are incorrect as there is no indication for heating pads or bra removal. Choice D is incorrect as there are no signs of mastitis present.
A nurse is caring for a client who is postpartum and finds the fundus slightly displaced to the right. Based on these findings, which of the following actions should the nurse take?
- A. Encourage the client to move to the left lateral position.
- B. Encourage the client to perform Kegel exercises.
- C. Assist the client to the bathroom to void.
- D. Ask the client to rate her pain.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to the bathroom to void. This action helps to empty the bladder, which can reduce uterine displacement. A full bladder can push the uterus to one side. Moving the client to the left lateral position (choice A) may not address the underlying issue of a full bladder. Kegel exercises (choice B) are not directly related to fundal displacement. Asking the client to rate her pain (choice D) is not relevant to the situation at hand.
A nurse is caring for several clients. The nurse should recognize that it is safe to administer tocolytic therapy to which of the following clients?
- A. A client who is experiencing preterm labor at 26 weeks of gestation.
- B. A client who is experiencing Braxton-Hicks contractions at 36 weeks of gestation.
- C. A client who has a post-term pregnancy at 42 weeks of gestation.
- D. A client who is experiencing fetal death at 32 weeks of gestation.
Correct Answer: A
Rationale: The correct answer is A: A client who is experiencing preterm labor at 26 weeks of gestation. Tocolytic therapy is used to inhibit uterine contractions and delay preterm labor. Administering tocolytic therapy to a client experiencing preterm labor at 26 weeks helps prevent premature birth and its associated complications. Choices B, C, and D are incorrect because Braxton-Hicks contractions at 36 weeks, post-term pregnancy at 42 weeks, and fetal death at 32 weeks do not warrant tocolytic therapy as they are not indicative of preterm labor.
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse should take which of the following actions?
- A. Place a finger at the base of the newborn’s toes.
- B. Turn the newborn’s head quickly to one side.
- C. Hold the newborn vertically allowing one foot to touch the table surface.
- D. Perform a sharp hand clap near the infant.
Correct Answer: D
Rationale: The Moro reflex is a startle reflex observed in newborns. To elicit this reflex, a sudden loud noise or movement is needed. Performing a sharp hand clap near the infant is the appropriate action to trigger the Moro reflex. This action mimics a sudden loud noise, causing the baby to extend the arms and legs, then bring them back in a hugging motion. Placing a finger at the base of the newborn's toes (Choice A) does not elicit the Moro reflex. Turning the newborn's head quickly to one side (Choice B) triggers the asymmetric tonic neck reflex, not the Moro reflex. Holding the newborn vertically allowing one foot to touch the table surface (Choice C) elicits the stepping reflex, not the Moro reflex.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use
- B. Blunt force trauma
- C. Hypertension
- D. Cigarette smoking
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption because it can lead to reduced blood flow to the placenta, increasing the risk of separation. High blood pressure can cause damage to the blood vessels in the placenta, making it more susceptible to detachment. Cocaine use (A) and cigarette smoking (D) can also increase the risk of abruption, but they are not as common as hypertension. Blunt force trauma (B) can directly cause placental abruption but is not as prevalent as hypertension in this context.