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An African American woman noticed bruises on a newborn girl's buttocks, and she asks the nurse who spanked the baby? The nurse responds
- A. Mongolian spots
- B. Ecchymosis
- C. Birth trauma
- D. Petechiae
Correct Answer: A
Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.
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The patient came for an induction and under which circumstances does the nurse remove prostaglandin from the patient's cervix? SATA
- A. N&V
- B. Late deceleration
- C. Contractions every 90 seconds
- D. Contractions every 5 minutes
Correct Answer: B
Rationale: A. Nausea and vomiting (N&V) are not typically indications for removing prostaglandin from the patient's cervix during induction. These symptoms are common side effects and can be managed without removing the prostaglandin.
Be- tions before finding one that works.
- A. Once you take the prescribed medication, you plan on teaching this client? will be cured of the infection.
- B. Breastfeeding
- C. Even though you don't experience symptoms,
- D. Postpartum depression you can still spread the infection.
Correct Answer: C
Rationale: Option C is the most appropriate statement to make to the client because it addresses the reality of sexually transmitted infections (STIs). Many STIs can be transmitted even when the infected individual is not experiencing any symptoms. This is an important point to communicate to prevent the spread of the infection to other sexual partners. It emphasizes the need for practicing safe sex measures and getting tested regularly, regardless of the presence of symptoms. It is important for the client to understand that they can still be a carrier of the infection even if they are not displaying any noticeable symptoms.
A patient who was diagnosed prenatally as having epidural for pain management. What should the greater than 2,000 mL of amniotic fluid just deliv- nurse be prepared to do? Select all that apply. ered a 9 lb (4,082 g) baby girl. Her nurse is aware
- A. Assess maternal vital signs that she is now at risk for which condition?
- B. Assess FHR
- C. Infection
- D. Assist patient to the bathroom to void
Correct Answer: A
Rationale: A. Assess maternal vital signs: With the delivery of a baby with macrosomia (greater than 4,000 g), the mother is at risk for postpartum hemorrhage due to uterine atony, retained placental fragments, or lacerations. Therefore, assessing maternal vital signs is crucial in detecting any signs of hemorrhage promptly.
A nurse is caring for a client who is 4hr postpartum and is experiencing hypovolemic shock. Which of the following actions should the nurse take?
- A. Administer indomethacin
- B. Insert a second using a 22-gauge IV catheter.
- C. Insert an indwelling urinary catheter.
- D. Administer oxygen at 4L/min via nasal cannula.
Correct Answer: B
Rationale: The priority action for a client experiencing hypovolemic shock is to restore circulating volume. Inserting a second IV using a 22-gauge catheter would allow for rapid administration of IV fluids to help restore blood volume and improve circulation. This intervention is crucial in managing hypovolemic shock to prevent further complications and stabilize the client's condition. Administering indomethacin, inserting an indwelling urinary catheter, or administering oxygen, while potentially necessary in some cases, are not the immediate priority in managing hypovolemic shock.
A patient who uses a diaphragm as contraception asks if they need to use a backup method. What should the nurse respond?
- A. No, the diaphragm is effective on its own and does not require a backup method.
- B. Yes, a diaphragm is effective only when used with spermicide, so a backup method is advised.
- C. Yes, a diaphragm should always be used with a condom for additional protection.
- D. No, but the diaphragm should be replaced every 6 months.
Correct Answer: B
Rationale: The diaphragm should be used with spermicide for maximum effectiveness. Choice A is incorrect because while the diaphragm is effective, spermicide enhances its performance and ensures greater protection. Choice C is unnecessary, as the diaphragm alone with spermicide is sufficient. Choice D is incorrect because while regular replacement is recommended, it does not require a backup method.