Nokea
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors paces the client at risk for infection.
- A. Meconium – start fluid
- B. placenta previa
- C. Midline episiotomy
- D. Prolonged labor
Correct Answer: C
Rationale: The correct answer is C: Midline episiotomy. Midline episiotomies are associated with a higher risk of infection due to the location being close to the anal canal, which harbors bacteria. The incision can become contaminated during bowel movements or urination, increasing the risk of infection. Placenta previa (B) is a condition related to the positioning of the placenta, not directly associated with infection risk. Meconium-stained amniotic fluid (A) may indicate fetal distress but does not directly increase the mother's risk of infection. Prolonged labor (D) can lead to increased risk of infection due to prolonged exposure to vaginal flora, but it is not as direct a risk factor as a midline episiotomy.
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A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. newborn who has nasal flaring
- B. newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring is a sign of respiratory distress, which is a priority because it indicates potential respiratory compromise. The nurse should assess this newborn first to ensure adequate oxygenation. Subconjunctival hemorrhage (choice B) and overlapping suture lines (choice C) are common findings in newborns and typically do not require immediate attention. Rust-stained urine (choice D) is not a concerning finding in a newborn and can be addressed later.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.
A nurse is assessing a client who is in preterm labor and has a new prescription for terbutaline 0.25 mg subcutaneous. For which of the following findings should the nurse withhold the medication and report to the provider?
- A. Fasting blood glucose 75 mg/dL
- B. Blood pressure 88/58 mmHg
- C. Urinary output 40 mL/hr
- D. FHR 120/min
Correct Answer: B
Rationale: Correct Answer: B (Blood pressure 88/58 mmHg)
Rationale: Terbutaline is a tocolytic medication used to inhibit preterm labor contractions by relaxing uterine smooth muscle. A low blood pressure of 88/58 mmHg indicates hypotension, a potential side effect of terbutaline. Hypotension can lead to decreased perfusion to the fetus and maternal organs, warranting withholding the medication and notifying the provider for further evaluation and management.
Summary of Incorrect Choices:
A: Fasting blood glucose 75 mg/dL - Normal blood glucose level, not a concerning finding related to terbutaline administration.
C: Urinary output 40 mL/hr - Normal urinary output, not a concerning finding related to terbutaline administration.
D: FHR 120/min - Normal fetal heart rate, not a concerning finding related to terbutaline administration.
A nurse is caring for a newborn who is 24 hr old. Which of the following Laboratory findings should the nurse report to the provider?
- A. Hgb 20 g/dL
- B. Bilirubin 2mg/dL
- C. Platelets 200 .000/mm3
- D. WBC count 32.000/mm3
Correct Answer: D
Rationale: The correct answer is D: WBC count 32,000/mm3. A newborn with a WBC count of 32,000/mm3 indicates a potential infection, as newborns typically have a higher WBC count initially due to stress of birth. It is important to report this finding to the provider for further evaluation and possible treatment. Choices A, B, and C are within normal range for a 24-hour-old newborn, so they do not require immediate reporting. Choice D, Hgb 20 g/dL, is not a typical laboratory finding for a newborn and would require further investigation, but it is not as urgent as a high WBC count indicating infection.
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.