Nokea
After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.
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While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
- A. Red reflex in the eyes.
- B. Expiratory grunt.
- C. Respiratory rate of 45 breaths/minute.
- D. Prominent xiphoid process.
Correct Answer: B
Rationale: An expiratory grunt is a sign of respiratory distress and warrants immediate notification of the pediatrician.
One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?
- A. Continue to monitor the client's fundus every 15 minutes.
- B. Ask the physician for an order for methylergonovine (Methergine).
- C. Immediately notify the physician of the client's symptoms.
- D. Change the client's perineal pads every 15 minutes.
Correct Answer: C
Rationale: Large clots and bright red bleeding post-delivery suggest possible uterine atony or retained placental fragments, requiring immediate physician notification for intervention. Monitoring, requesting medication, or changing pads are secondary actions.
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for:
- A. Puerperal infection.
- B. Vaginal lacerations.
- C. History of drug abuse.
- D. Perineal hematoma.
Correct Answer: D
Rationale: Persistent perineal pain unrelieved by ibuprofen suggests a perineal hematoma, which requires further assessment.
When reviewing the prenatal history for a newly delivered neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for:
- A. Caffé au lait spots.
- B. Port wine nevus.
- C. Strawberry hemangiomas.
Correct Answer: A
Rationale: Neurofibromatosis is associated with café au lait spots, which are a hallmark sign to assess in the neonate.
A 17-year-old client at 33 weeks' gestation diagnosed with mild preeclampsia is prescribed bed rest at home. The nurse instructs the client to contact the health care provider immediately if she experiences which of the following?
- A. Blurred vision.
- B. Ankle edema.
- C. Increased energy levels.
- D. Mild backache.
Correct Answer: A
Rationale: Blurred vision can indicate worsening preeclampsia and requires immediate medical attention.