Nokea
A nurse is walking down the hall in the main corridor of a hospital. The Code Pink infant security alert system sounds and a Code Pink alert is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?
- A. Move to the entrance of the hospital and check each person leaving.
- B. Go to the obstetrics unit to determine if they need help with the situation.
- C. Call the nursery to ask which baby is missing.
- D. Observe individuals in the area for large bags or oversized coats.
Correct Answer: D
Rationale: Observing for suspicious items like large bags helps identify potential abductors during a Code Pink.
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A laboring client with preeclampsia is prescribed magnesium sulfate 2 g/hour I.V. piggyback. The pharmacy sends the I.V. to the unit labeled magnesium sulfate 20 g/500 mL normal saline. To deliver the correct dose, the nurse should set the pump to deliver how many milliliters per hour?
Correct Answer: 50
Rationale: To calculate the correct dose: (2 g/hour * 500 mL) / 20 g = 50 mL/hour.
Which of the following would the nurse expect as a common finding for a multiparous client delivering a viable neonate at 41 weeks' gestation with the aid of a vacuum extractor?
- A. Caput succedaneum.
- B. Cephalohematoma.
- C. Maternal lacerations.
- D. Neonatal intracranial hemorrhage.
Correct Answer: A
Rationale: Vacuum extraction commonly causes caput succedaneum, a soft tissue swelling on the neonate's scalp due to pressure, which resolves spontaneously. Cephalohematoma, lacerations, or hemorrhage are less common or more serious.
The physician has ordered prostaglandin gel to be administered vaginally to a newly admitted primigravid client. Which of the following indicate that the client has had a therapeutic response to the medication?
- A. Resting period of 2 minutes between contractions.
- B. Normal patellar and elbow reflexes for the past 2 hours.
- C. Softening of the cervix and beginning effacement.
- D. Leaking of clear amniotic fluid in small amounts.
Correct Answer: C
Rationale: Prostaglandin gel is used for cervical ripening. A therapeutic response is indicated by cervical softening and effacement, preparing the cervix for labor. Resting periods and reflexes are unrelated to the gel's purpose, and leaking amniotic fluid suggests rupture of membranes, not a direct effect of the gel.
A woman who has delivered a healthy newborn is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?
- A. Bleeding that becomes lighter each day.
- B. Clots the size of golf balls.
- C. Saturating a pad in an hour.
- D. Lochia that last longer than 1 week.
Correct Answer: C
Rationale: Saturating a pad in an hour indicates excessive bleeding.
An obese 36-year-old multigravid client at 12 weeks' gestation has a history of chronic hypertension. She was treated with methyldopa(Aldomet) before becoming pregnant. When counseling the client about diet during pregnancy, the nurse realizes that the client needs additional instruction when she states which of the following?
- A. "I need to reduce my caloric intake to 1,200 calories a day."
- B. "A regular diet is recommended during pregnancy."
- C. "I should eat more frequent meals if I get heartburn."
- D. "I need to consume more fluids and fiber each day."
Correct Answer: A
Rationale: Reducing caloric intake too much can be harmful during pregnancy.