Nokea
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to drug withdrawal. Seizure precautions involve ensuring a safe environment, padded crib, monitoring vital signs closely, and having emergency medications and equipment readily available. Monitoring blood glucose every hour (A) is not typically necessary for neonatal abstinence syndrome. Placing the infant on their back with legs extended (B) is a basic positioning technique and not specific to addressing the syndrome. Providing a stimulating environment (D) would be inappropriate and could exacerbate symptoms.
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A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because dinoprostone is a medication used to induce labor, which carries risks and requires informed consent. Without informed consent, the client may not fully understand the potential risks and benefits of the medication.
Choice A is incorrect because room temperature is not a specific requirement for administering dinoprostone. Choice B is incorrect as there is no evidence to support placing the client in a semi-Fowler's position after administration. Choice C is incorrect as avoiding urinary elimination is not necessary for this medication.
In summary, obtaining informed consent is the most important action to ensure the client understands the implications of the medication, making choice D the correct answer.
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 is to massage the client's fundus. This is because excessive vaginal bleeding postpartum could indicate uterine atony, which is a common cause of postpartum hemorrhage. By massaging the fundus, the nurse can help stimulate uterine contractions and reduce bleeding. Administering oxytocin (choice B) may be necessary but massaging the fundus should be done first. Emptying the client's bladder (choice C) can also help, but addressing uterine atony is the priority. Providing oxygen (choice D) is not the immediate action needed for excessive vaginal bleeding.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce swelling, promote healing, and provide comfort for the client with a fourth-degree laceration. Warm compress can improve circulation and help with pain relief.
Choice B: Providing a cool sitz bath may not be ideal for promoting healing in this case as warmth is more beneficial.
Choice C: Administering methylergonovine is not appropriate for a perineal laceration and can cause unwanted side effects.
Choice D: Applying povidone-iodine after voiding can be irritating to the already sensitive area and may delay healing.
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 that can occur postpartum. Uterine tenderness is a common finding in clients with endometritis due to inflammation and infection. A: A temperature of 37.4°C (99.3°F) is within normal range and may not specifically indicate endometritis. B: A WBC count of 9,000/mm3 is also within normal limits and may not be specific to endometritis. D: Scant lochia may be seen in clients with endometritis, but it is not a defining characteristic.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.