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A woman admitted to the labor and delivery unit in bruising over the shoulder area and an abrasion on early labor gives the following obstetric history. She the scalp. What are these markings most likely the gave birth to her daughter at 38 weeks and her twin result of?
- A. Suspected drug use during pregnancy
- B. Abuse by a caregiver
- C. Soft tissue injury during delivery
- D. Blue/gray macule (Mongolian spot)
Correct Answer: B
Rationale: The bruising over the shoulder area and the abrasion on the scalp of a woman admitted to the labor and delivery unit during early labor are most likely the result of abuse by a caregiver. These types of injuries can be indicative of physical abuse, especially in vulnerable populations such as pregnant women. It is important for healthcare providers to be alert for signs of abuse and to report any suspicions or evidence to ensure the safety of the mother and the baby. In cases like this, a thorough assessment and appropriate intervention are necessary to protect the well-being of the mother and the unborn child.
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A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.
The nurse is assessing a client at 10 weeks' gestation. Which finding is expected?
- A. Quickening.
- B. Fetal heart tones by Doppler.
- C. Fundus at the level of the umbilicus.
- D. Presence of Braxton Hicks contractions.
Correct Answer: B
Rationale: Fetal heart tones can typically be detected by Doppler around 10 weeks' gestation.
A patient has just had a Mirena IUD inserted. What is the most important information for the nurse to include in the post-procedure instructions?
- A. You may experience severe cramping and should rest for several days.
- B. You should check the strings of the IUD regularly to ensure it is in place.
- C. You should avoid sexual activity for the first month after the insertion.
- D. The IUD will make your periods longer and heavier for the first 6 months.
Correct Answer: B
Rationale: The patient should be instructed to check the strings of the IUD regularly to ensure it remains in place. Choice A is not accurate because while cramping is common, rest is not necessarily required for several days. Choice C is not required; there is no need to avoid sexual activity unless there is an infection or other complication. Choice D is incorrect as Mirena typically reduces bleeding or makes periods lighter.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.