Nokea
A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
- A. Cephalohematoma
- B. Caput succedaneum
- C. Subdural hematoma
- D. Molding
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It results from trauma during birth and typically resolves on its own.
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A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?
- A. Naloxone
- B. Epinephrine
- C. Atropine
- D. Diazepam
Correct Answer: A
Rationale: Meperidine is an opioid analgesic that can cross the placenta and cause respiratory depression in the newborn. Naloxone is an opioid antagonist that is administered to reverse the effects of opioids. It is critical to have Naloxone available when opioids are administered during labor, especially close to delivery.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion
- B. Administer oxygen at 10 L/min via nonrebreather face mask
- C. Discontinue the infusion of oxytocin
- D. Place the client in a left lateral position
Correct Answer: C
Rationale: The first action should be to discontinue the infusion of oxytocin, as it can contribute to uterine hyperstimulation and fetal distress. This allows for immediate assessment and management of the fetal heart rate.
A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?
- A. A yearly Pap test is recommended until 70 years of age.
- B. Pap tests are discontinued following removal of the ovaries.
- C. Avoid having sexual intercourse for 24 hours prior to the Pap test.
- D. Viral infections can be detected by a Pap test.
Correct Answer: C
Rationale: Clients should avoid sexual intercourse for 24 hours prior to the Pap test to ensure accurate results, as it can affect the sample. Pap tests are typically performed every 3 years for women aged 21-29 and every 3-5 years for women aged 30-65.
A client is being treated with eclampsia. What is a priority nursing intervention?
- A. Assess for hyperreflexia
- B. Administer oxygen
- C. Monitor blood pressure every 15 minutes
- D. Prepare for delivery
Correct Answer: A
Rationale: Eclampsia is a serious complication of pregnancy characterized by seizures. Hyperreflexia is often a precursor to eclampsia, and assessing for it can help predict and manage the condition before seizures occur.
A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct Answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences.