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A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia is a common cause. Low blood glucose in a newborn can lead to seizures and long-term neurological damage. Monitoring blood glucose levels and promptly addressing any abnormalities is crucial. Total bilirubin (B) is important for assessing jaundice, not jitteriness. Hemoglobin (C) and blood calcium (D) are not typically related to jitteriness in a newborn.
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A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important to prevent skin irritation and infection in newborns. Washing the baby's face with plain water helps to keep the delicate skin clean without introducing any harsh chemicals or irritants. It is gentle and safe for the baby's sensitive skin.
Summary of why the other choices are incorrect:
A: Bathing the baby immediately after a feeding can lead to discomfort and potential issues with digestion.
B: Placing a bumper pad in the baby's crib increases the risk of suffocation and Sudden Infant Death Syndrome (SIDS).
C: Putting a soft mattress in the crib can pose a suffocation hazard and increase the risk of SIDS.
E, F, G: No additional choices provided.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: Rationale: Choice C, anticipating a prescription for misoprostol, is correct. Misoprostol helps to contract the uterus and control bleeding in cases of uterine atony postpartum. Administering betamethasone (A) is used for fetal lung development, not for uterine atony. Avoiding sterile vaginal exams (B) is not helpful in managing uterine atony. Obtaining a specimen for a Kleihauer-Betke test (D) is used to detect fetal-maternal hemorrhage, not to manage uterine atony.
A nurse is assessing a client who is 1 hr postpartum following a vaginal birth. The nurse notes that the client has excessive vaginal bleeding. Which of the following actions should the nurse take first?
- A. Massage the client's fundus.
- B. Administer oxytocin to the client.
- C. Empty the client’s bladder.
- D. Provide oxygen to the client via nonrebreather face mask.
Correct Answer: A
Rationale: The correct action for the nurse to take first in this situation is to massage the client's fundus. This is because excessive vaginal bleeding postpartum can indicate uterine atony, which is the most common cause of postpartum hemorrhage. Massaging the fundus helps stimulate uterine contractions, which will help to control the bleeding. It is important to address this issue promptly to prevent further complications. Administering oxytocin (choice B) can also help with uterine contractions, but massaging the fundus should be done first. Emptying the client's bladder (choice C) can relieve pressure on the uterus, but it is not the priority in this situation. Providing oxygen (choice D) is not necessary unless the client is showing signs of hypoxia, which is not indicated in the scenario.
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule involves adding 7 days to the first day of the last menstrual period, subtracting 3 months, and then adding 1 year. In this case, starting from August 10, add 7 days to get August 17. Next, subtract 3 months to get May 17, and finally add 1 year to get the estimated date of delivery as May 17. Choice A (May 13) is incorrect as it does not follow the correct calculation steps. Choice C (May 3) is incorrect as it miscalculates the months. Choice D (May 20) is incorrect as it does not consider the subtraction of 3 months.