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A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
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Which condition is a transient self-limiting mood disorder that affects new moms after childbirth?
- A. Postpartum blues
- B. Postpartum depression
- C. Postpartum psychosis
- D. Generalized anxiety disorder
Correct Answer: A
Rationale: The correct answer is A: Postpartum blues. This condition is a common, self-limiting mood disorder that affects new moms after childbirth. It is characterized by mild symptoms such as mood swings, weepiness, and irritability, usually resolving within a few weeks. Postpartum depression (B) is more severe and long-lasting, with persistent feelings of sadness, hopelessness, and anxiety. Postpartum psychosis (C) is a rare but serious condition marked by hallucinations, delusions, and extreme mood swings, requiring immediate medical attention. Generalized anxiety disorder (D) is a chronic condition characterized by excessive worry and anxiety unrelated to specific events, different from the transient nature of postpartum blues.
The nurse understands that many patients who experience violence become homeless to escape their situation. How can the nurse help these patients?
- A. Tell the patient to go back home in order to have a place to live.
- B. Tell the patient to get a job in order to have a place to stay.
- C. Refer the patient to a shelter.
- D. Refer the patient to the police.
Correct Answer: C
Rationale: The correct answer is C: Refer the patient to a shelter. This option is the most appropriate because it addresses the immediate need for a safe place to stay for patients experiencing violence and homelessness. Referring the patient to a shelter provides them with temporary housing, safety, and access to resources and support services. Options A and B are not suitable as they overlook the safety concerns of the patient and may put them at risk of further harm. Option D, referring the patient to the police, may not address the patient's need for shelter and support services. Therefore, option C is the most effective and compassionate way to help patients in this situation.
The nurse is performing a prenatal assessment. What finding is considered a positive sign of pregnancy?
- A. Positive pregnancy test.
- B. Auscultation of fetal heart tones.
- C. Hegar's sign.
- D. Chadwick's sign.
Correct Answer: B
Rationale: The correct answer is B, auscultation of fetal heart tones, because it is a definitive sign of pregnancy indicating the presence of a fetus. This can be heard around 10-12 weeks of gestation using a Doppler device. It is a positive sign as it directly confirms the existence of a developing fetus.
A: A positive pregnancy test is a probable sign and can indicate pregnancy but is not definitive.
C: Hegar's sign is a probable sign characterized by softening of the lower uterine segment, not specific to pregnancy.
D: Chadwick's sign is a probable sign of pregnancy indicated by bluish discoloration of the cervix, vagina, and labia, not a definitive sign of pregnancy.
The nurse is preparing a client for cesarean delivery. What is the priority nursing action before surgery?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Administer prophylactic antibiotics.
- D. Verify signed informed consent.
Correct Answer: D
Rationale: The correct answer is D, verifying signed informed consent. This is the priority because it ensures the client's understanding and agreement to the procedure, respecting their autonomy. Obtaining baseline vital signs (A) is important but not the priority before surgery. Inserting a urinary catheter (B) may be needed but is not the priority over informed consent. Administering antibiotics (C) is important for preventing infection but should not take precedence over confirming the client's informed consent.
The nurse is preparing a client for induction of labor. What is the purpose of administering oxytocin?
- A. Stimulate uterine contractions.
- B. Relieve pain during labor.
- C. Promote cervical ripening.
- D. Reduce maternal blood pressure.
Correct Answer: A
Rationale: The correct answer is A: Stimulate uterine contractions. Oxytocin is administered to induce labor by increasing the frequency and strength of uterine contractions. This helps progress labor and facilitate delivery. Choice B is incorrect as pain relief is usually achieved through analgesics or anesthesia. Choice C is incorrect because cervical ripening is typically promoted with medications like prostaglandins. Choice D is also incorrect as oxytocin can actually cause a temporary increase in blood pressure.