Nokea
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial in preventing infection, as the leaking cerebrospinal fluid puts the newborn at risk for meningitis. Antibiotics help reduce the risk of infection until surgical closure can be performed. Monitoring rectal temperature (B) is important but not the priority. Cleansing the site with povidone-iodine (C) may further irritate the area. Planning for surgical closure after 72 hr (D) is important, but immediate infection prevention is the priority.
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The nurse is teaching the client about postpartum depression. The nurse should encourage the client to----------------- and ----------------- to help prevent postpartum depression.
- A. Engage in regular physical activity
- B. Maintain a strong support system
- C. Get adequate rest and sleep
- D. Eat a well-balanced diet
Correct Answer:
Rationale: The nurse should encourage the client to:Engage in regular physical activity – Exercise can help boost mood, reduce stress, and improve overall well-being, which may help prevent postpartum depression. Maintain a strong support system – Connecting with family, friends, or support groups can provide motional support, reduce feelings of isolation, and help manage postpartum stress.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: Oligohydramnios, or low amniotic fluid, is an indication for electronic fetal monitoring as it can be associated with fetal distress and other complications.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in FHR during oxytocin infusion indicate uteroplacental insufficiency. Administering oxygen helps improve oxygenation to the fetus, potentially alleviating the late decelerations. This action addresses the underlying cause and supports fetal oxygenation. In contrast, option A may increase intrauterine pressure, worsening fetal distress. Option C (supine position) can further compromise placental perfusion. Option D (amnioinfusion) is used for variable decelerations, not late decelerations.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The nurse assessed the client to be 80% effaced and 8 cm dilated, indicating she is in active labor. This client is at risk for postpartum hemorrhage, which is excessive bleeding after childbirth due to the uterus not contracting adequately to control bleeding. The risk is higher in clients who have a rapid labor progression like this client. Ectopic pregnancy (A) is not relevant in this scenario as the client is already in labor. Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, not related to the client's current condition. Incompetent cervix (C) is the premature dilation of the cervix, not applicable at this stage of labor.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: C, D
Rationale: The correct manifestations of SSRI withdrawal in a newborn are bradypnea (C) and vomiting (D). SSRI use during pregnancy can lead to neonatal withdrawal symptoms due to drug exposure in utero. Bradypnea is a common withdrawal symptom characterized by slow breathing rate in newborns. Vomiting is another withdrawal symptom that can occur in newborns exposed to SSRIs. Large for gestational age (A) and hyperglycemia (B) are not typical manifestations of SSRI withdrawal. Therefore, the nurse should focus on monitoring for bradypnea and vomiting as signs of SSRI withdrawal in the newborn.