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Before taking the newborn's vital signs, the nurse should warm his or her hands and the stethoscope to prevent heat loss resulting from which of the following?
- A. Evaporation.
- B. Conduction.
- C. Radiation.
- D. Convection.
Correct Answer: B
Rationale: Cold surfaces cause conductive heat loss.
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On admission to the maternity unit, it is learned that a mother has smoked 2 packs of cigarettes per day and expects to continue to smoke after discharge. The mother also states that she expects to breastfeed her baby. The nurse's response should be based on which of the following?
- A. Breastfeeding is contraindicated if the mother smokes cigarettes.
- B. Breastfeeding is protective for the baby and should be encouraged.
- C. A 2-pack-a-day smoker should be reported to child protective services for child abuse.
- D. A mother who admits to smoking cigarettes may also be abusing illicit substances.
Correct Answer: B
Rationale: Breastfeeding provides benefits despite maternal smoking.
A client is receiving a blood transfusion after the delivery of a placenta accreta and hysterectomy. Which of the following complaints by the client would warrant immediately discontinuing the infusion?
- A. My lower back hurts all of a sudden.
- B. My hands feel so cold.
- C. I feel like my heart is beating fast.
- D. I feel like I need to have a bowel movement.
Correct Answer: A
Rationale: Back pain can indicate a hemolytic reaction.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
- A. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
- B. The mother covers the glans with antifungal ointment after rinsing off any discharge.
- C. The mother squeezes soapy water from the wash cloth over the glans.
- D. The mother replaces the dry sterile dressing before putting on the diaper.
Correct Answer: D
Rationale: Proper care involves keeping the area clean and dry, with a sterile dressing if necessary.
The nurse assesses for signs of depression or postpartum blues. How can the nurse explain the difference?
- A. PPD is less severe and resolves in a few weeks.
- B. Postpartum blues can last up to a year.
- C. PPD is a normal expectation of postpartum.
- D. Postpartum blues symptoms include irritability and sadness.
Correct Answer: D
Rationale: The correct answer is D because postpartum blues typically involve symptoms like irritability and sadness, which are common and usually resolve within a few weeks. This is different from postpartum depression (PPD), which is more severe and may last longer. A is incorrect because PPD is typically more severe than postpartum blues. B is incorrect because postpartum blues usually resolve within a few weeks, not up to a year. C is incorrect because PPD is not considered a normal expectation of postpartum, as it requires intervention and treatment.
A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
- A. Magnesium 7 mg/dL.
- B. Sodium 136 mg/dL.
- C. Potassium 3.0 mg/dL.
- D. Calcium 9 mg/dL.
Correct Answer: A
Rationale: Elevated magnesium levels indicate toxicity.