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A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
- A. 3+ protein in the urine.
- B. Deep tendon reflexes of 1+.
- C. Blood pressure 148/98 mm Hg.
- D. 1+ pitting sacral edema.
Correct Answer: B
Rationale: The correct answer is B. Deep tendon reflexes of 1+ are inconsistent with preeclampsia. In preeclampsia, deep tendon reflexes are typically hyperactive (3+ or 4+). This is due to the central nervous system irritability caused by hypertension. Therefore, a reflex of 1+ suggests normal reflexes, which is not expected in preeclampsia. Other choices A, C, and D are consistent with preeclampsia. Proteinuria (choice A) is a hallmark sign of preeclampsia. Elevated blood pressure (choice C) is a common finding in preeclampsia. Pitting edema (choice D) is also commonly observed in preeclampsia due to fluid retention.
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A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
- A. Drying the newborn’s skin thoroughly.
- B. Preventing air drafts.
- C. Placing the newborn on a warm surface.
- D. Maintaining ambient room temperature at 24°C (75.2°F).
Correct Answer: A
Rationale: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (B) and placing the newborn on a warm surface (C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (D) is important for thermoregulation but does not directly address evaporative heat loss.
A nurse is completing a home visit to a mother who is 3 days postpartum and breastfeeding her newborn. The mother expresses concern about the amount of weight the newborn has lost since birth. Which of the following is a response the nurse should make?
- A. “The cause might be too short or infrequent feedings.”
- B. “It is due to the newborn’s loss of the influence of the maternal hormones.”
- C. “This might be related to your baby having 3 stools a day.”
- D. “You might want to offer water supplements between feedings.”
Correct Answer: A
Rationale: The correct answer is A because insufficient feeding can lead to excessive weight loss in newborns. Frequent and effective breastfeeding helps ensure the baby receives enough milk and nutrients. Option B is incorrect as maternal hormones do not directly affect newborn weight loss. Option C is incorrect as the number of stools is not necessarily indicative of weight loss. Option D is incorrect as newborns should only be fed breastmilk or formula, not water supplements.
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
- A. Dorsogluteal
- B. Vastus lateralis
- C. Deltoid
- D. Ventrogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice D) can be used in older infants but is not the preferred site for newborns.
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
- A. Products of conception will be present in vaginal bleeding.
- B. Increased intake of zinc-rich foods is recommended.
- C. Vaginal intercourse can be resumed after 2 weeks.
- D. Aspirin may be taken for cramps.
Correct Answer: C
Rationale: The correct answer is C: Vaginal intercourse can be resumed after 2 weeks. This is important to prevent infection and allow the cervix to heal. Choice A is incorrect as products of conception are typically expelled during the D&C procedure. Choice B is irrelevant as zinc intake is not directly related to post-D&C care. Choice D is incorrect as aspirin can increase the risk of bleeding post-D&C.