Nokea
A viable female neonate was delivered 10 minutes ago and is in stable condition under a radiant warmer. To prevent infant heat loss by convection, the nurse should:
- A. Move the infant away from cool window surfaces.
- B. Dry the infant quickly after delivery.
- C. Keep the infant away from air conditioning vents.
- D. Place the infant on a warmed surface.
Correct Answer: C
Rationale: Keeping the infant away from air conditioning vents prevents heat loss by convection, which occurs due to air movement.
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Prophylactic heparin therapy is ordered to treat thrombophlebitis in a multiparous client who delivered 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which of the following as the purpose of the drug?
- A. To thin the blood clots.
- B. To increase the lochial flow.
- C. To increase the perspiration for diuresis.
- D. To prevent further blood clot formation.
Correct Answer: D
Rationale: Heparin prevents further clot formation in thrombophlebitis without dissolving existing clots.
A multigravid client diagnosed with a probable ruptured ectopic pregnancy is scheduled for emergency surgery. In addition to monitoring the client's blood pressure before surgery, which of the following would the nurse assess?
- A. Uterine cramping.
- B. Abdominal distention.
- C. Hemoglobin and hematocrit.
- D. Pulse rate.
Correct Answer: D
Rationale: Pulse rate helps assess circulatory status.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client complains of severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in a position that is identified as which of the following?
- A. Breech.
- B. Transverse.
- C. Posterior.
- D. Anterior.
Correct Answer: C
Rationale: Severe back pain in labor is commonly associated with a posterior occiput position (e.g., occipitoposterior), where the fetal head presses against the maternal sacrum. Breech, transverse, or anterior positions are less likely to cause intense back pain.
After reinforcing the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statements would demonstrate her understanding of when to call the physician's office? Select all that apply.
- A. "If I get up in the morning and feel dizzy, even if the dizziness goes away."
- B. "If I see any bleeding, even if I have no pain."
- C. "If I have a pounding headache that doesn't go away."
- D. "If I notice the veins in my legs getting bigger."
- E. "If the leg cramps at night are waking me up."
- F. "If the baby seems to be more active than usual."
Correct Answer: A,B,C,F
Rationale: These symptoms could indicate complications needing medical attention.
The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?
- A. A neonate born at 36 weeks' gestation.
- B. A neonate born by Cesarean section.
- C. A neonate experiencing apneic episodes.
- D. A neonate who is 42 weeks' gestation.
Correct Answer: C
Rationale: A neonate experiencing apneic episodes is at greatest risk for RDS due to compromised respiratory function.