Nokea
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rho(D) immune globulin
- B. A client who gave birth 3 days ago and reports breast fullness
- C. A client who gave birth 12 hr ago and reports an increase in urinary output
- D. A client who gave birth 8 hr ago and is saturating a perineal pad every hour
Correct Answer: D
Rationale: The client saturating a perineal pad every hour may be experiencing postpartum hemorrhage, which is a medical emergency requiring immediate assessment and intervention.
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A laboring client received meperidine IV one hour prior to delivery. Which of the following medications should the nurse have available to counteract the effects of this medication on the newborn?
- A. Naloxone
- B. Epinephrine
- C. Atropine
- D. Diazepam
Correct Answer: A
Rationale: Meperidine is an opioid analgesic that can cross the placenta and cause respiratory depression in the newborn. Naloxone is an opioid antagonist that is administered to reverse the effects of opioids. It is critical to have Naloxone available when opioids are administered during labor, especially close to delivery.
A nurse is caring for a newborn who has respiratory distress. Which of the following actions should the nurse take first?
- A. Administer oxygen via nasal cannula
- B. Place the newborn in a prone position
- C. Suction the newborn's airway
- D. Notify the healthcare provider
Correct Answer: C
Rationale: In cases of respiratory distress, the nurse should first suction the newborn's airway to clear any obstructions. This is a non-invasive procedure that can quickly improve breathing.
A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Hypertonia
- B. Jitteriness
- C. Acrocyanosis
- D. Generalized petechiae
Correct Answer: B
Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy.
Which of the following would increase a client's risk of ovarian cancer?
- A. History of fibroids
- B. Early menopause
- C. Endometriosis
- D. Polycystic ovary syndrome
Correct Answer: C
Rationale: Endometriosis is associated with an increased risk of developing ovarian cancer due to chronic inflammation and hormonal imbalances. The exact cause is not fully understood, but women with endometriosis should be monitored closely.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hr
- B. Apply moisturizing lotion to the newborn's skin every 4 hr
- C. Give the newborn 1 oz of glucose water every 4 hr
- D. Reposition the newborn every 2 to 3 hr
Correct Answer: D
Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin.