Nokea
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. Newborn who has nasal flaring
- B. Newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: Nasal flaring in a newborn can be a sign of respiratory distress, which is a critical condition that requires immediate attention. It indicates that the newborn is having difficulty breathing and may not be getting enough oxygen. This can be due to various reasons such as lung problems, infections, or other respiratory issues. Therefore, the nurse should assess and address the newborn with nasal flaring first to ensure their breathing is stable and adequate.
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An adolescent patient calls the office and asks to speak with the nurse. The patient cannot remember where she can place her contraceptive patch. What area of the body should the nurse tell her to avoid?
- A. breasts
- B. abdomen
- C. buttocks
- D. arm
Correct Answer: A
Rationale: The nurse should advise the adolescent patient to avoid placing the contraceptive patch on her breasts. The contraceptive patch is typically recommended to be placed on areas of the body with minimal hair and movement to ensure proper adherence and absorption of hormones. Placing the patch on the breasts may result in movement and friction, causing it to become dislodged or less effective. It is important to follow the specific instructions provided with the contraceptive patch on where to apply it for optimal effectiveness.
The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?
- A. At the first prenatal visit.
- B. Between 35–37 weeks' gestation.
- C. During the second trimester.
- D. After 40 weeks' gestation.
Correct Answer: B
Rationale: GBS testing is typically performed between 35–37 weeks to identify and manage infection risks during delivery.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action?
- A. Verify signed informed consent.
- B. Administer prescribed analgesics.
- C. Encourage the client to empty their bladder.
- D. Position the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.
4 minutes after the birth of the baby there is a sudden gush of blood from the mom's vagina and the about 8 inches of umbilical cord slides out. What action should nurse take first?
- A. Watch for emergence of placenta
- B. Assess for signs of uterine inversion
- C. Perform fundal massage
- D. Prepare for possible episiotomy repair
Correct Answer: A
Rationale: In this situation, the nurse should first watch for the emergence of the placenta. This is because the gush of blood followed by the umbilical cord slipping out indicates a possible placental abruption, where the placenta separates from the uterine wall before the baby is born. It is crucial to closely monitor the situation for signs of an incomplete placental delivery or any further complications. If the placenta does not deliver within a reasonable timeframe or if there are signs of excessive bleeding or other issues, immediate medical intervention may be necessary.
What immediate action should a nurse take for a mother reporting a severe headache postpartum?
- A. Administer analgesics and monitor blood pressure
- B. Encourage the mother to rest
- C. Apply a cold compress to the mother's head
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: A severe headache postpartum can indicate preeclampsia or other serious conditions requiring immediate action.