Nokea
A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
- A. Placement of the neonate on a ventilator.
- B. Administration of bronchodilators through the nurse.
- C. Suctioning of the neonate's nares with wall suction.
- D. Insertion of a chest tube into the neonate.
Correct Answer: D
Rationale: These symptoms suggest a pneumothorax, and inserting a chest tube is the priority to relieve air trapping.
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A nurse is teaching a client about the use of condoms for contraception. Which of the following statements by the client indicates understanding of the teaching?
- A. Condoms must be stored in a hot, humid environment.
- B. Condoms can be reused if washed thoroughly.
- C. Condoms provide some protection against STIs.
- D. Condoms are 100% effective in preventing pregnancy.
Correct Answer: C
Rationale: Condoms provide some protection against sexually transmitted infections, which is a key benefit. They should be stored in a cool, dry place, cannot be reused, and are not 100% effective in preventing pregnancy.
A 24-year-old primigravid client who delivers a viable term neonate is ordered to receive the primary effect of the placenta. Which of the following signs would indicate to the nurse that the placenta is about to be delivered?
- A. The cord lengthens outside the vagina.
- B. There is decreased vaginal bleeding.
- C. The uterus cannot be palpated.
- D. Uterus changes to discoid shape.
Correct Answer: A
Rationale: A lengthening umbilical cord outside the vagina indicates placental separation and descent, signaling imminent delivery. Decreased bleeding or a non-palpable uterus are not reliable signs, and the uterus becomes globular, not discoid, after placental delivery.
Approximately 90 minutes after birth, the nurse should encourage the mother of a term neonate to do which of the following?
- A. Feed the neonate.
- B. Allow the neonate to sleep.
- C. Get to know the neonate.
- D. Change the neonate's diaper.
Correct Answer: A
Rationale: Feeding within 90 minutes promotes bonding, stabilizes blood glucose, and initiates breastfeeding or formula feeding.
A client asks about the side effects of the vaginal contraceptive ring. Which of the following would the nurse include?
- A. Nausea and breast tenderness may occur.
- B. It causes permanent infertility.
- C. It requires surgical insertion.
- D. It guarantees regular periods.
Correct Answer: A
Rationale: Nausea and breast tenderness are possible side effects of the vaginal contraceptive ring, especially initially. It does not cause permanent infertility, require surgical insertion, or guarantee regular periods.
A laboring client smiles pleasantly at the nurse when asked simple questions. The client speaks no English and the interpreter is busy with an emergency situation. At her last vaginal examination, the client was 5 cm dilated, 100% effaced, and at 0 station. While working with this client, which of the following responses indicates that the client may be approaching delivery?
- A. The fetal monitor strip shows late decelerations.
- B. The client begins to speak to her family in her native language.
- C. The fetal monitor strip shows early decelerations.
- D. The client's facial expressions become animated.
Correct Answer: D
Rationale: Animated facial expressions (e.g., grimacing, distress) may indicate transition or second-stage labor, suggesting imminent delivery. Late decelerations indicate fetal distress, speaking to family is nonspecific, and early decelerations are normal.