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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This should be the first action taken because ensuring the correct identification of the newborn is crucial for providing appropriate care. Incorrect identification could lead to serious consequences, such as administering medications or treatments to the wrong infant. Confirming the newborn's Apgar score (choice A) or administering vitamin K (choice C) can wait until the identification is verified. Determining obstetrical risk factors (choice D) is important but not the immediate priority.
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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.
The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
- E. exercise 30 min per day
Correct Answer: B,E
Rationale: The correct answers are B and E. Maintaining a strong support system is crucial for emotional well-being, as it provides the client with reassurance, understanding, and help in times of need. This can help prevent feelings of isolation and loneliness, common in postpartum depression. Additionally, exercising for at least 30 minutes per day can release endorphins, improve mood, and reduce stress, all of which can contribute to preventing postpartum depression. Choices A, C, and D are important for overall health but do not specifically address the emotional and mental aspects that can lead to postpartum depression.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: The correct answer is C: Hypotension. Opioid analgesics can cause vasodilation, leading to a drop in blood pressure. The nurse should monitor for hypotension as a potential adverse effect, as this can result in dizziness and decreased perfusion. Hyperglycemia (A) is not typically associated with opioid analgesics. Bilateral crackles (B) are more indicative of fluid overload or pulmonary edema. Polyuria (D) is excessive urination and is not a common adverse effect of opioid analgesics.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates a lack of uterine tone, which can lead to postpartum hemorrhage. Administering oxytocin helps to stimulate contractions, restoring uterine tone and reducing bleeding. Excess vaginal bleeding is also an indication for oxytocin as it helps to control bleeding by promoting uterine contractions. Choices B, D, and the remaining options do not directly relate to the need for oxytocin administration in postpartum care. A cervical laceration would require appropriate wound management, and increased afterbirth cramping may not necessarily warrant oxytocin administration unless coupled with other signs of uterine atony.
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.