Nokea
A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: Pseudomenstruation is a normal finding due to hormonal withdrawal.
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The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?
- A. Variability
- B. Accelerations
- C. Early decelerations
- D. Variable decelerations
Correct Answer: D
Rationale: Variable decelerations are a hallmark sign of umbilical cord compression, requiring immediate monitoring and intervention.
Which of the following actions is appropriate for the nurse to take regarding a 9-year-old girl diagnosed with gonorrhea?
- A. Notify the physician so the child can be admitted to the hospital.
- B. Discuss with the girl the need to stop future sexual encounters.
- C. Question the mother about her daughter's menstrual history.
- D. Report the girl's medical findings to child protective services.
Correct Answer: D
Rationale: Gonorrhea in a 9-year-old girl is highly suggestive of sexual abuse, which requires reporting to child protective services.
In teaching parents to use a bulb syringe to suction an infant, the nurse should teach them to:
- A. suction the back of the throat vigorously.
- B. always suction the nose before suctioning the mouth.
- C. use it only once a day.
- D. insert the syringe into the sides of the mouth.
Correct Answer: B
Rationale: Suctioning the nose first prevents pushing secretions further down the throat.
Relaxation of muscles in labor provides many benefits. What is one benefit of this technique in labor?
- A. Relaxation will prevent a cesarean section.
- B. Relaxation of the pelvic floor helps in pushing the fetus in the second stage.
- C. Relaxation of the abdomen ensures an unmedicated birth.
- D. Relaxation causes the contractions to decrease in strength.
Correct Answer: B
Rationale: Relaxing the pelvic floor facilitates smoother fetal descent during the second stage of labor.
To maximize absorption, what supplement should a client take with calcium?
- A. Vitamin D.
- B. Vitamin E.
- C. Folic acid.
- D. Iron.
Correct Answer: A
Rationale: Vitamin D enhances calcium absorption.