Nokea
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, “How will I know if my baby gets enough breast milk?” Which of the following responses should the nurse make?
- A. Your baby should wet 6 to 8 diapers per day.
- B. Your baby should have a wake cycle of 30 to 60 minutes after each feeding.
- C. Your baby should burp after each feeding.
- D. Your baby should sleep at least 6 hours between feedings.
Correct Answer: A
Rationale: The correct answer is A: Your baby should wet 6 to 8 diapers per day. This is because the frequency of wet diapers indicates that the newborn is getting enough breast milk. An adequate amount of wet diapers signifies that the baby is adequately hydrated and receiving sufficient nourishment. It is a concrete and measurable way to monitor the baby's intake.
Choice B is incorrect because the wake cycle after feeding varies among newborns and is not a reliable indicator of milk intake. Choice C is incorrect as burping after feeding is a normal process but not necessarily an indicator of sufficient milk intake. Choice D is incorrect because newborns typically need to feed more frequently than every 6 hours.
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A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
- A. Rapid decline in human chorionic gonadotropin (hCG) levels
- B. Irregular fetal heart rate
- C. Excessive uterine enlargement
- D. Profuse, clear vaginal discharge
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal growth of placental tissue in the uterus, leading to excessive uterine enlargement. This condition results in the absence of a viable fetus and can cause symptoms such as vaginal bleeding, severe nausea, and hypertension. The other choices are incorrect because: A) Rapid decline in hCG levels is not a typical finding in a hydatidiform mole, as hCG levels are usually elevated. B) Irregular fetal heart rate is not applicable in this case since there is no viable fetus. D) Profuse, clear vaginal discharge is not a characteristic symptom of a hydatidiform mole. E, F, and G are not provided as options.
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Absent plantar reflexes
- C. Lengthened thigh on the affected side
- D. Asymmetric thigh folds
Correct Answer: D
Rationale: The correct answer is D: Asymmetric thigh folds. In DDH, there is an abnormal formation of the hip joint which can lead to dislocation. Asymmetric thigh folds result from the shortened thigh muscles on the affected side due to the dislocation. This finding is indicative of DDH as it reflects the displacement of the femoral head. The other choices are incorrect because an inwardly turned foot (A) is associated with clubfoot, absent plantar reflexes (B) may indicate neurological issues, and a lengthened thigh (C) is not a typical finding in DDH.
A nurse is monitoring a client who is 3 days postpartum and is breastfeeding. The nurse notes that the fundus is three fingerbreadths below the umbilicus, lochia rubra is moderate, and the breasts are full and warm to palpation. Which of the following interpretations of these findings should the nurse make?
- A. Additional interventions not indicated at this time.
- B. Application of a heating pad to the breasts is indicated.
- C. The client should be advised to remove her nursing bra.
- D. The client is exhibiting early indications of mastitis.
Correct Answer: A
Rationale: Rationale: The nurse should interpret the findings as normal for a client 3 days postpartum. The fundus being 3 fingerbreadths below the umbilicus is within the expected range. Moderate lochia rubra is normal postpartum bleeding. Full and warm breasts are expected signs of lactation. Choice A is correct because the findings do not indicate any complications requiring additional interventions at this time. Choices B and C are incorrect as there is no indication for heating pads or bra removal. Choice D is incorrect as there are no signs of mastitis present.
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?
- A. Turning on the apnea#nbsp;apnea and cardiorespiratory monitor.
- B. Connecting the resuscitation bag to oxygen.
- C. Setting up the radiant warmer control temperature at 36.4°C (97.5°F).
- D. Preparing for the insertion of an intravenous (IV) line with D5W.
Correct Answer: B
Rationale: The correct answer is B: Connecting the resuscitation bag to oxygen. This intervention is the priority because the infant has low Apgar scores, indicating poor oxygenation and respiratory effort. Providing oxygen through the resuscitation bag will help improve oxygenation and support the infant's breathing, which is crucial in the immediate postnatal period.
Turning on the apnea and cardiorespiratory monitor (Choice A) may be important for continuous monitoring but addressing the oxygenation issue takes precedence. Setting up the radiant warmer control temperature (Choice C) is important for maintaining the infant's body temperature but not the immediate priority. Preparing for IV insertion with D5W (Choice D) is not necessary at this moment as the priority is to address the respiratory distress.