Nokea
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 protect the newborn's eyes from exposure to the bright light used in phototherapy, which can cause damage if the eyes are left open. Closing the eyes with eyepatches ensures that the light therapy is safely administered without harming the eyes.
A: Providing glucose water is not relevant to managing jaundice with phototherapy.
B: Turning the newborn every 4 hours is important for preventing pressure ulcers, but it is not directly related to phototherapy.
C: Applying hydrating lotion is not necessary before phototherapy and may interfere with the treatment.
E, F, G: Not provided.
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A nurse is providing teaching to a client who is 2 days postpartum and wants to continue using her diaphragm for contraception. Which of the following instructions should the nurse include?
- A. You should have your provider refit you for a new diaphragm.'
- B. You should use an oil-based vaginal lubricant when inserting your diaphragm.'
- C. You should keep the diaphragm in place for at least 4 hours after intercourse.'
- D. You should store your diaphragm in sterile water after each use.'
Correct Answer: A
Rationale: The correct answer is A: "You should have your provider refit you for a new diaphragm." This is important because postpartum changes in the body can affect the fit of the diaphragm. A refitting ensures proper size and fit for effective contraception. Choice B is incorrect because oil-based lubricants can damage latex diaphragms. Choice C is incorrect as the diaphragm should be kept in place for at least 6-8 hours, not 4 hours, for effective contraception. Choice D is incorrect as diaphragms should be stored dry, not in sterile water, to prevent damage.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding is associated with Down Syndrome, which requires further evaluation by the provider. Single palmar creases are a physical characteristic commonly seen in infants with Down Syndrome. Reporting this to the provider allows for early intervention and appropriate management. Choices B, C, D, and E are incorrect because Down Syndrome (choice B) is not a clinical finding to report but rather a condition associated with single palmar creases. Rust-stained urine (choice C) may indicate hematuria but is not a common concern in newborns. Transient circumoral cyanosis (choice D) is a common finding in newborns that usually resolves on its own. Subconjunctival hemorrhage (choice E) is also a common and benign finding in newborns.
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 potential complication like uterine prolapse. Deep tendon reflexes 1+ could suggest a neurological issue or electrolyte imbalance. A pain rating of 3 on a scale of 0 to 10 (increased) requires further assessment to determine the cause and provide appropriate treatment. Choices D, E, F, and G are not as urgent. Peripheral edema 2+ bilateral lower extremities could be indicative of fluid retention, which may need monitoring but not immediate intervention. Soft uterine tone may be expected postpartum, and a large amount of lochia rubra could be normal after birth. A blood pressure of 136/86 mm Hg is slightly elevated but not critically high, so it may require monitoring but not immediate follow-up.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios
- B. Hyperemesis gravidarum
- C. Leukorrhea
- D. Periodic tingling of the fingers
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess fetal well-being by monitoring the baby's heart rate and uterine contractions. Oligohydramnios, which is low amniotic fluid levels, can indicate fetal distress and compromise, necessitating closer monitoring. Hyperemesis gravidarum (B) is severe nausea and vomiting, not directly related to fetal monitoring. Leukorrhea (C) is normal vaginal discharge during pregnancy and not a reason for fetal monitoring. Periodic tingling of the fingers (D) is unrelated to fetal assessment.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: Correct Answer: A. Assist the client to ambulate to the bathroom.
Rationale: By assisting the client to ambulate to the bathroom, the nurse is promoting normal physiological functioning. Walking can help stimulate the bladder and promote urination, which is often needed after a cesarean birth due to the effects of anesthesia and limited mobility. It also helps prevent complications like urinary retention or urinary tract infections. Encouraging the client to move also aids in promoting circulation, preventing blood clots, and enhancing overall recovery.
Summary of other choices:
B: Inserting an indwelling catheter should not be the first intervention as it can increase the risk of infection and discomfort.
C: Performing a bladder scan is not necessary as the client's symptoms do not indicate a need for immediate assessment of urine volume.
D: Administering a diuretic is not appropriate without assessing the client's condition further as it may not address the underlying issue and could exacerbate any existing problems.