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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.
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A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: Correct Answer: C - Initiate seizure precautions.
Rationale: Infants with neonatal abstinence syndrome are at risk for seizures due to drug withdrawal. Initiating seizure precautions involves creating a safe environment to prevent injury during a seizure. This includes padding the crib, ensuring a clear space around the infant, and having emergency medications available. Monitoring blood glucose levels every hour (A) is not directly related to neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a basic positioning technique and does not address the specific needs of a baby with neonatal abstinence syndrome. Providing a stimulating environment (D) is contraindicated as it can exacerbate symptoms of withdrawal in the infant.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: Correct Answer: D - Respiratory distress
Rationale: Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing dysfunction in respiratory centers. This can manifest as tachypnea, grunting, nasal flaring, and retractions. Hypertonia, increased feeding, and hyperthermia are not specific signs of hypoglycemia in newborns.
Summary:
A: Hypertonia is not a typical manifestation of hypoglycemia in newborns.
B: Increased feeding is more likely to be seen in newborns with hunger cues, not necessarily indicative of hypoglycemia.
C: Hyperthermia is not a common sign of hypoglycemia in newborns.
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.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G. A Coombs test result should be reported as it indicates potential hemolytic anemia. Mucous membrane assessment is crucial for hydration status and oxygenation. Intake and output levels are key indicators of kidney function and hydration status. Sclera color can indicate liver function or anemia. Choices D, E, and F are important assessments but do not typically require immediate reporting unless they are outside of normal ranges and affecting the patient's condition.
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.