Nokea
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale:
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A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: At 12 weeks of gestation, the fetal heart rate is best assessed using an ultrasound stethoscope positioned above the symphysis pubis. Leopold maneuvers are not necessary at this early stage.
A nurse is reviewing the chart of a client who is 2 days postpartum following a vaginal delivery and reports constipation. Which of the following findings should the nurse identify as a contraindication to the use of a suppository?
- A. Vaginal candidiasis
- B. Abdominal distention
- C. Afterpains
- D. Third-degree perineal laceration
Correct Answer: D
Rationale: The correct answer is D: Third-degree perineal laceration. Using a suppository in a client with a third-degree perineal laceration can exacerbate pain, increase the risk of infection, and hinder the healing process. The suppository insertion may disrupt the delicate tissue, leading to further trauma and complications. It is crucial to allow the perineal area to heal properly without additional irritation. Choices A, B, and C are not contraindications to the use of a suppository for constipation in a postpartum client. Vaginal candidiasis, abdominal distention, and afterpains do not directly impact the safety or effectiveness of suppository use in this scenario.
A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. To protect the newborn's eyes from potential damage due to phototherapy light, it is essential to close the eyes before placing eyepatches. This prevents exposure to the bright light, reducing the risk of eye irritation or injury. Providing glucose water (A), turning the newborn every 4 hours (B), and applying hydrating lotion (C) are not directly related to the phototherapy treatment for jaundice. Closing the eyes before applying eyepatches is crucial for the safety and comfort of the newborn during the phototherapy session.
For each finding, click to specity if the finding increases the client's risk for uterine atony or infection.
- A. Prenatal anemia
- B. High parity
- C. Prolonged rupture of membranes
- D. Cesarean birth
- E. Polyhydramnios
Correct Answer:
Rationale:
Which of the following is a potential cause of female infertility?
- A. Polycystic ovary syndrome (PCOS)
- B. Endometriosis
- C. Pelvic inflammatory disease (PID)
- D. All of the above
Correct Answer: D
Rationale: Female infertility can be caused by PCOS, endometriosis, or pelvic inflammatory disease (PID).