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 assessing a client with hyperemesis gravidarum. What finding requires immediate intervention?
- A. Urine output of 50 mL/hr.
- B. Weight loss of 5 pounds in 2 weeks.
- C. Dry mucous membranes and poor skin turgor.
- D. Nausea relieved by eating crackers.
Correct Answer: C
Rationale: Dehydration, indicated by dry mucous membranes and poor skin turgor, requires immediate intervention in hyperemesis gravidarum.
During the first few minutes after birth which physiologic changes occurs in the newborn as response to vascular pressure changes in increased oxygen levels?
- A. Dilation of pulmonary vessel (dilation of pulmonary vessels occurs in response to increased oxygen levels)
Correct Answer: A
Rationale: Immediately after birth, as the newborn takes its first breaths and transitions to breathing air, there is a rapid increase in oxygen levels in the blood. This sudden increase in oxygen causes the pulmonary vessels in the newborn's lungs to dilate. This dilation helps improve blood flow through the lungs, allowing for efficient exchange of oxygen and carbon dioxide. The dilation of pulmonary vessels is a normal physiologic response to the changing environment in the newborn's body after birth.
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.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
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.