Nokea
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates a lack of uterine tone, which can lead to postpartum hemorrhage. Administering oxytocin helps to stimulate contractions, restoring uterine tone and reducing bleeding. Excess vaginal bleeding is also an indication for oxytocin as it helps to control bleeding by promoting uterine contractions. Choices B, D, and the remaining options do not directly relate to the need for oxytocin administration in postpartum care. A cervical laceration would require appropriate wound management, and increased afterbirth cramping may not necessarily warrant oxytocin administration unless coupled with other signs of uterine atony.
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A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. In newborns of mothers with gestational diabetes, they are at risk for hypoglycemia due to the sudden drop in glucose levels after birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating neurological impairment. Abdominal distention (A) is not typically associated with hypoglycemia. Petechiae (B) are tiny red or purple spots on the skin and are not specific to hypoglycemia. Increased muscle tone (C) is more commonly seen in conditions like cerebral palsy. Jitteriness (D) is a typical sign of hypoglycemia in newborns and requires prompt attention to prevent further complications.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can result in weakness or paralysis of facial muscles. Polycythemia (choice A) is not typically associated with forceps-assisted births. Hypoglycemia (choice B) may occur in newborns for various reasons, but it is not directly related to the birth method. Bronchopulmonary dysplasia (choice C) is a lung condition usually seen in premature infants, not specifically linked to forceps deliveries. In summary, facial palsy is the most likely complication of forceps-assisted births due to the pressure exerted on the baby's face during the delivery process.
A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client’s history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
Correct Answer: A, B, D
Rationale: The correct answer is A, B, D. Cholecystitis is a contraindication due to increased risk of gallbladder disease with oral contraceptives. Hypertension is a contraindication because estrogen in oral contraceptives can worsen hypertension. Migraine headaches with aura are a contraindication due to increased risk of stroke. Human papillomavirus is not a contraindication unless it is accompanied by other conditions.
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct answer is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically not done to determine the sex of the fetus but rather to identify genetic abnormalities or congenital disorders. Providing this information allows the client to make informed decisions about their pregnancy and potential interventions.
A: You cannot have an amniocentesis until you are at least 35 years of age - This statement is incorrect as age alone is not the sole criteria for recommending amniocentesis.
C: Your provider will schedule a chorionic villus sampling to determine the sex of your baby - Chorionic villus sampling is also not typically done to determine the sex of the fetus.
D: We can schedule the procedure for later today if you’d like - This is incorrect as scheduling an amniocentesis without a medical indication is not appropriate.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a serious condition like preeclampsia, a potentially life-threatening pregnancy complication. The nurse should instruct the client to report this immediately to the provider for further evaluation and management. Shortness of breath when climbing stairs (A), swelling of feet and ankles at the end of the day (B), and Braxton Hicks contractions (D) are common occurrences in pregnancy and not usually indicative of immediate complications. Therefore, they do not require urgent reporting compared to the unrelieved headache as mentioned in choice C.