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 nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5° C (97.7° F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct Answer: B
Rationale: Nasal flaring can indicate respiratory distress and should be reported immediately for further evaluation.
Prior to an amniocentesis, what action by the client will need to be completed?
- A. Increase fluid intake
- B. Empty the bladder
- C. Avoid eating for 12 hours
- D. Take a sedative
Correct Answer: B
Rationale: Before an amniocentesis, the client should empty her bladder to reduce the risk of bladder puncture during the procedure. This is especially important in early pregnancy.
A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
- A. Drink large amounts of water before bedtime
- B. Perform Kegel exercises regularly
- C. Limit fiber in the diet to avoid bowel irritation
- D. Increase intake of caffeinated and carbonated beverages
Correct Answer: B
Rationale: Kegel exercises help strengthen the pelvic floor muscles, which can improve bladder control and reduce urinary incontinence. The nurse should instruct the client to practice these exercises regularly.
A nurse is assessing a pregnant client at 32 weeks gestation and notes that the client has gained 5 pounds in one week. Which of the following conditions should the nurse suspect?
- A. Preeclampsia
- B. Gestational diabetes
- C. Anemia
- D. Placenta previa
Correct Answer: A
Rationale: Rapid weight gain, especially in the third trimester, can be a sign of preeclampsia, a condition characterized by hypertension, edema, and proteinuria. This requires immediate medical attention.
A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?
- A. Administer oxygen via nasal cannula
- B. Place the newborn in a prone position
- C. Suction the newborn's airway
- D. Notify the healthcare provider
Correct Answer: C
Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a non-invasive procedure that can quickly improve breathing.