Nokea
A patient receives an epidural anesthesia during the first stage of labor. The epidural is discontinued immediately after delivery. The patient is at an increased risk of which problem during the fourth stage of labor?
- A. Bladder distention
- B. Postpartum hemorrhage
- C. Deep vein thrombosis (DVT)
- D. Infection
Correct Answer: A
Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.
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A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance ... that crosses the suture line. The nurse should identify the swellings as which of the following....?
- A. Nevus flammeus
- B. Caput uccedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: C
Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.
The nurse is reviewing the role of the placenta in fetal development. Which statement should be included?
- A. The placenta stores nutrients for the fetus.
- B. The placenta prevents all infections from reaching the fetus.
- C. The placenta transfers oxygen and nutrients to the fetus.
- D. The placenta produces progesterone only in early pregnancy.
Correct Answer: C
Rationale: The placenta facilitates the transfer of oxygen and nutrients while removing waste products.
Which statement by the patient helps the nurse know
- A. Follicle-stimulating hormone she understands the teaching about condom use?
- B. Gonadotropin-releasing hormone
- C. A condom can be worn for two sexual encounters
- D. Progesterone as long as it does not break.
Correct Answer: A
Rationale: The statement "Condoms come in different sizes; it is important I get the right size to ensure proper protection" indicates that the patient understands the teaching about condom use. This statement shows an understanding of the importance of choosing the appropriate condom size for effective protection during sexual encounters. It reflects the patient's grasp of the information provided by the nurse regarding condom use, which is crucial in promoting safe practices to prevent sexually transmitted infections and unintended pregnancies.
The nurse is caring for a client with preeclampsia. What is the primary goal of magnesium sulfate therapy?
- A. To reduce blood pressure.
- B. To prevent seizures.
- C. To improve fetal circulation.
- D. To treat headaches.
Correct Answer: B
Rationale: Magnesium sulfate is administered in preeclampsia primarily to prevent eclampsia-related seizures.
A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
- A. Administer nitric oxide inhalation therapy to the newborn
- B. Insert an orogastric decompression tube with low wall suction.
- C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
- D. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.
Correct Answer: D
Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.