Nokea
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can lead to further trauma and delayed wound healing. Suppositories are contraindicated in such cases to prevent infection and promote proper healing.
A: Vaginal candidiasis is not a contraindication for using a suppository, as it can actually help in treating the infection.
B: Abdominal distention would not necessarily contraindicate the use of a suppository.
C: Afterpains are common postpartum and do not specifically contraindicate the use of a suppository.
E, F, G: No other options provided.
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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. This action is appropriate because late decelerations in fetal heart rate (FHR) can indicate uteroplacental insufficiency, leading to fetal hypoxia. Administering oxygen helps increase the oxygen supply to the fetus, potentially improving fetal oxygenation and reducing the risk of hypoxia-related complications.
Choice A is incorrect because bearing down and pushing with contractions can further compromise fetal oxygenation in the presence of late decelerations. Choice C is incorrect as a supine position can worsen uteroplacental perfusion. Choice D, initiating an amnioinfusion, is not indicated for addressing late decelerations in FHR.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This step is crucial to ensure the client understands the risks and benefits of the procedure. It promotes client autonomy and helps prevent legal issues.
A: Allowing the medication to reach room temperature is not a necessary step for administering dinoprostone insert.
B: Placing the client in a semi-Fowler's position is not indicated after administering dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could be harmful to the client.
E, F, G: No other options are provided, but they would likely be incorrect as well.
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. Infants born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply post-birth. Jitteriness is a common manifestation of hypoglycemia in newborns, indicating the need for prompt intervention to prevent further complications. Abdominal distention (A) is not typically associated with hypoglycemia. Petechiae (B) are small red or purple spots on the skin caused by bleeding under the skin and are not directly related to hypoglycemia. Increased muscle tone (C) is not a typical sign of hypoglycemia in newborns.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and closure. It acknowledges the baby's existence and validates the client's experience. Choice A may be incorrect as it could deprive the client of the opportunity to spend time with their baby for closure. Choice C is incorrect as it may not be necessary in all cases and could be overwhelming for the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Feed the newborn 5 to 10 min per breast.
- B. Offer the newborn 30 mL (1 oz) of water between feedings.
- C. Expect two to four wet diapers every 24 hr.
- D. Allow the baby to feed at least every 3 hr.
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hours. This is crucial for maintaining the baby's nutrition and ensuring an adequate milk supply. Breastfeeding on demand helps establish a healthy feeding pattern and promotes bonding between the mother and baby. Option A is incorrect because newborns should feed until they are satisfied, not based on time. Option B is incorrect as newborns should not be given water as it can interfere with breastfeeding and lead to water intoxication. Option C is incorrect as newborns should have at least 6-8 wet diapers a day.