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A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: Correct Answer: D. Notify the provider if the end of your baby’s penis appears dark red.
Rationale: Dark red appearance at the end of the baby's penis could indicate infection or poor blood flow, requiring immediate medical attention to prevent complications. This information is crucial for parents to recognize potential risks post-circumcision.
Summary of other choices:
A: The Plastibell is usually removed after a few days, not 4 hours. Incorrect.
B: Snug diapers can cause irritation. Not relevant to Plastibell circumcision. Incorrect.
C: Yellow exudate forming in 24 hours is normal post-circumcision. Not concerning. Incorrect.
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A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement
- B. Leakage of fluid from the vagina
- C. Upper abdominal discomfort
- D. Urinary frequency
Correct Answer: B
Rationale: Correct Answer: B - Leakage of fluid from the vagina
Rationale: Following an amniocentesis at 18 weeks of gestation, leakage of fluid from the vagina could indicate a potential complication such as premature rupture of membranes. This complication could lead to preterm labor and pose a risk to both the mother and the fetus.
Summary of Other Choices:
A: Increased fetal movement - Normal fetal movement is expected following an amniocentesis and does not necessarily indicate a complication.
C: Upper abdominal discomfort - Common after an amniocentesis due to the needle insertion but usually resolves without major issues.
D: Urinary frequency - Not directly related to complications following an amniocentesis at 18 weeks gestation.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: Correct Answer: A. Assist the client to ambulate to the bathroom.
Rationale: By assisting the client to ambulate to the bathroom, the nurse is promoting normal physiological functioning. Walking can help stimulate the bladder and promote urination, which is often needed after a cesarean birth due to the effects of anesthesia and limited mobility. It also helps prevent complications like urinary retention or urinary tract infections. Encouraging the client to move also aids in promoting circulation, preventing blood clots, and enhancing overall recovery.
Summary of other choices:
B: Inserting an indwelling catheter should not be the first intervention as it can increase the risk of infection and discomfort.
C: Performing a bladder scan is not necessary as the client's symptoms do not indicate a need for immediate assessment of urine volume.
D: Administering a diuretic is not appropriate without assessing the client's condition further as it may not address the underlying issue and could exacerbate any existing problems.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is crucial because the occipitoposterior position can cause intense back pain during labor. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve the client's discomfort. A: "Does that lessen your suprapubic pain?" is incorrect because suprapubic pain is not specifically associated with occipitoposterior positioning. B: "Are you feeling relief from your pelvic pressure?" is incorrect as it does not directly address the back pain associated with occipitoposterior positioning. C: "Do your contractions feel further apart?" is incorrect as it does not focus on the back pain issue. The key is to address the specific discomfort caused by the occipitoposterior position.
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is essential to prevent compression and drying of the umbilical cord, which could lead to fetal hypoxia and compromise fetal circulation. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain fetal perfusion until delivery can be expedited. Performing a vaginal examination (choice A) could further compress the cord and worsen the situation. Administering oxygen (choice C) may be beneficial but is not the priority in this urgent situation. Initiating IV fluids (choice D) is not the immediate priority when fetal bradycardia and umbilical cord prolapse are present.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because the client's water breaking indicates a potential risk to the fetus, such as umbilical cord compression or prolapse. FHR monitoring helps assess fetal well-being and detect any signs of distress. Performing Nitrazine testing (A) and checking cervical dilation (C) can wait until after ensuring fetal safety. Assessing the fluid (B) may provide some information but does not directly address the immediate concern for fetal well-being.