Nokea
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. When a newborn is born with a nuchal cord (umbilical cord wrapped around the neck), compression can occur, leading to facial petechiae. This occurs due to the increased pressure on the blood vessels in the face during delivery. Telangiectatic nevi (A) are unrelated to nuchal cord. Periauricular papillomas (C) are benign skin lesions often found in newborns but are not specific to nuchal cord. Erythema toxicum (D) is a common benign rash in newborns, but it is not directly associated with a nuchal cord.
You may also like to solve these questions
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by symptoms such as irritability, high-pitched crying, tremors, and poor feeding due to withdrawal from substances the mother used during pregnancy. Excessive crying is a common manifestation of this syndrome. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may indicate other neurological or developmental issues.
A nurse is caring for a client who is 12 hr postpartum and has a fourth-degree laceration of the perineum. Which of the following actions should the nurse take?
- A. Apply a moist, warm compress to the perineum.
- B. Provide the client with a cool sitz bath.
- C. Administer methylergonovine 0.2 mg IM.
- D. Apply povidone-iodine to the client’s perineum after she voids.
Correct Answer: A
Rationale: The correct answer is A: Apply a moist, warm compress to the perineum. This action helps to reduce pain and swelling, promotes healing, and improves comfort. Moist heat increases blood flow to the area, which can aid in the healing process.
Choice B: Providing a cool sitz bath may provide some relief from discomfort, but warm compresses are more effective for promoting healing in this case.
Choice C: Administering methylergonovine is not indicated for a fourth-degree perineal laceration. This medication is used to prevent or control postpartum hemorrhage.
Choice D: Applying povidone-iodine to the perineum is not recommended as it may cause irritation and delay healing.
In summary, choice A is the most appropriate action as it promotes healing and comfort for the client with a fourth-degree perineal laceration. Choices B, C, and D are not recommended in this situation.
A nurse is caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, white vaginal discharge
- B. Urinary frequency
- C. Vulva lesions
- D. Malodorous discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, leading to a characteristic foul-smelling vaginal discharge. This discharge is typically greenish-yellow, frothy, and may be accompanied by itching or irritation. Thick, white discharge (choice A) is more indicative of a yeast infection. Urinary frequency (choice B) is not a common symptom of trichomoniasis. Vulva lesions (choice C) are more likely to be seen in other infections or conditions. Therefore, the malodorous discharge is the most specific finding associated with trichomoniasis at 20 weeks of gestation.
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule states to add 7 days to the first day of the last menstrual period, then subtract 3 months, and add 1 year. In this case, August 10 + 7 days = August 17. Subtracting 3 months gives us May 17. This date is the estimated date of delivery. Choice A (May 13) is incorrect as it does not follow Nägele's Rule. Choice C (May 3) is too early based on the calculation. Choice D (May 20) is too late as it exceeds the estimated date.
A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hr ago. Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply.)
- A. Labor induction with oxytocin
- B. Newborn weight 2.948 kg (6 lb 8 oz)
- C. Vacuum-assisted delivery
- D. History of uterine atony
- E. History of human papillomavirus
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Labor induction with oxytocin can lead to uterine hyperstimulation, increasing the risk of postpartum hemorrhage.
C: Vacuum-assisted delivery can cause trauma to the birth canal, leading to increased risk of bleeding.
D: A history of uterine atony indicates a weakened ability of the uterus to contract post-delivery, increasing the risk of hemorrhage.
B: Newborn weight is not directly related to postpartum hemorrhage risk.
E: History of human papillomavirus does not directly impact postpartum hemorrhage risk.