Nokea
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.
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A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?
- A. Accidental lacerations
- B. Respiratory distress
- C. Hypothermia
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Respiratory distress. The nurse's priority is to ensure the newborn's ability to breathe effectively. Respiratory distress is common after cesarean delivery due to fluid in the lungs. Addressing this promptly is critical to prevent complications. Accidental lacerations (A) are important but not immediately life-threatening. Hypothermia (C) can be addressed after ensuring the newborn's respiratory status. Acrocyanosis (D) is a common finding in newborns and not an urgent concern.
A nurse is caring for a client who is 6 hours postpartum. The client is Rh-negative and her newborn is Rh-positive. The client asks why an indirect Coombs test was ordered by the provider. Which of the following is an appropriate response by the nurse?
- A. It detects Rh-positive antibodies in the mother’s blood.
- B. It determines the presence of maternal antibodies in the newborn’s blood.
- C. It detects Rh-negative antibodies in the newborn’s blood.
- D. It determines if kernicterus will occur in the newborn.
Correct Answer: A
Rationale: The correct answer is A because the indirect Coombs test detects Rh-positive antibodies in the mother's blood. In Rh incompatibility, Rh-negative mothers can develop antibodies against Rh-positive fetal blood, which can lead to hemolytic disease of the newborn. This test helps identify the presence of these antibodies to prevent harm to the newborn. Choice B is incorrect because the test is done on the mother's blood, not the newborn's. Choice C is incorrect as it refers to the wrong blood type. Choice D is incorrect as kernicterus is related to severe jaundice, not Rh incompatibility.
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
- A. Ask the client if she has considered harming her newborn.
- B. Anticipate a prescription by the provider for an antidepressant.
- C. Reinforce postpartum and newborn care discharge teaching.
- D. Assist the family to identify proper use of positive coping skills in family crises.
Correct Answer: A
Rationale: The correct answer is A. The nurse should ask the client if she has considered harming her newborn as she is experiencing symptoms of postpartum depression. This is a critical step to assess the client's safety and the baby's well-being. Other choices are incorrect as B assumes the need for medication without further assessment, C focuses on teaching rather than immediate safety concerns, and D does not address the client's mental health state. By asking about harming the newborn, the nurse can assess the severity of the client's condition and provide appropriate interventions.
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Prepare the newborn for transport to the NICU.
- B. Call the provider to further assess the newborn.
- C. Ask another nurse to verify the heart rate.
- D. Document this as an expected finding.
Correct Answer: D
Rationale: The correct answer is D: Document this as an expected finding. In a newborn, a heart rate of 130/min is within the normal range (120-160/min). The nurse does not need to take any immediate action as this heart rate is considered normal for a newborn. Documenting this finding is important for ongoing assessment and continuity of care.
Choice A is incorrect because there is no indication for transport to the NICU based solely on the heart rate. Choice B is unnecessary as further assessment is not warranted for a normal heart rate. Choice C is not needed as the nurse is capable of accurately assessing the heart rate.
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.