Nokea
A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman's vital signs, which finding would be of greatest concern to the nurse?
- A. Temperature 37.9°C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg.
- B. Temperature 37.4°C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg.
- C. Temperature 38°C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg.
- D. Temperature 36.8°C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg.
Correct Answer: A
Rationale: An estimated blood loss (EBL) of 1500 ml following a vaginal birth is significant and can lead to hypovolemia. The vital signs provided in option A (Temperature 37.9°C, heart rate 120 bpm, respirations 20 breaths per minute, and blood pressure 90/50 mm Hg) indicate tachycardia and hypotension, which are concerning signs of hypovolemia due to excessive blood loss. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased blood volume, and hypotension indicates inadequate perfusion. Options B, C, and D do not exhibit the same level of concern for hypovolemia. Option B shows tachypnea, which can be a result of pain or anxiety postpartum. Option C and D have vital signs within normal limits, which are not indicative of the body's response to significant blood loss.
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A client in the transition phase of labor reports a pain level of 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage.
- B. Apply counterpressure to the client's sacrum.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: During the transition phase of labor, a client may experience intense back pain due to the pressure of the baby descending. Applying counterpressure to the client's sacrum can help alleviate this discomfort. Effleurage is a light stroking massage technique that may not provide adequate relief for intense back pain. Patterned-paced breathing is beneficial for managing contractions but may not directly address back pain. Biofeedback is a technique that helps individuals gain awareness and control of certain physiological functions, but it may not be the most appropriate intervention for acute labor pain.
Which of the following statements about Rh incompatibility is true?
- A. Rh incompatibility occurs most commonly during a woman's first pregnancy.
- B. Rh incompatibility is an untreatable condition that leaves a woman infertile for the rest of her life.
- C. Rh incompatibility is an abnormality that is transmitted from generation to generation and carried by a sex chromosome.
- D. Rh incompatibility occurs due to antibodies transmitted to a fetus during subsequent deliveries causing brain damage or death.
Correct Answer: D
Rationale: Rh incompatibility occurs when the mother's antibodies attack the fetus's red blood cells, leading to serious complications, usually in subsequent pregnancies. Choice A is incorrect because Rh incompatibility often occurs in subsequent pregnancies, not necessarily the first one. Choice B is incorrect as Rh incompatibility does not render a woman infertile but can lead to complications during pregnancies. Choice C is incorrect as Rh incompatibility is not carried by a sex chromosome but involves the Rh factor on red blood cells.
A 16-year-old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan?
- A. Allow liberal family visitation
- B. Keep an airway at the bedside
- C. Assess temperature every hour
- D. Monitor blood pressure, pulse, and respiration every 4 hours
Correct Answer: B
Rationale: Keeping an airway at the bedside is crucial for a client with eclampsia, as there is a high risk of seizures that can obstruct the airway. Allowing liberal family visitation (choice A) may not be a priority at this time and can be overwhelming for the client. Assessing temperature every hour (choice C) is not directly related to managing eclampsia. Monitoring blood pressure, pulse, and respiration every 4 hours (choice D) is important but not as immediate as ensuring airway patency.
When both of the alleles for a trait, such as hair color, are the same, the person is said to be _____ for that trait.
- A. monozygous
- B. dizygous
- C. homozygous
- D. hemizygous
Correct Answer: C
Rationale: A person is homozygous for a trait when they have two identical alleles for that trait. In this case, both alleles are the same, indicating a homozygous genotype. Choice A, 'monozygous,' is incorrect as it refers to identical twins originating from a single fertilized egg. Choice B, 'dizygous,' is also incorrect as it refers to fraternal twins or individuals that develop from two separate fertilized eggs. Choice D, 'hemizygous,' is incorrect because it describes a genetic condition where only one allele is present in a diploid organism, typically related to genes on the sex chromosomes.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a calm environment
- B. Monitor blood glucose levels every hour
- C. Initiate seizure precautions
- D. Place the infant on their back with legs extended
Correct Answer: C
Rationale: Initiating seizure precautions is crucial when caring for an infant with neonatal abstinence syndrome due to the increased risk of seizures. Providing a calm environment (Choice A) is important to reduce stimulation as these infants may be irritable. Monitoring blood glucose levels (Choice B) is not typically a priority in neonatal abstinence syndrome unless specific signs or symptoms suggest the need for this assessment. Placing the infant on their back with legs extended (Choice D) does not directly address the potential complications associated with neonatal abstinence syndrome, such as seizures.