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. Initiate anticoagulant therapy, Administer an oxytocic medication, Apply ice packs to the breasts.
- B. Engorgement, Urinary tract infection, Deed vein thrombosis
- C. Temperature, Circumference of lower extremities, Integrity of the nipples
Correct Answer:
Rationale:
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A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open
- C. Both fontanels are the same size.
- D. Both fontanels show molding.
Correct Answer: B
Rationale: The anterior fontanel typically remains open until around 18 months of age, while the posterior fontanel usually closes by 2-3 months. Molding is not an expected finding at this age.
Which stage of labor is characterized by cervical dilation from 4-10 cm?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: A
Rationale: The correct answer is A: First stage. This stage of labor is characterized by cervical dilation from 4-10 cm. During this stage, the cervix prepares for childbirth by thinning and opening up to allow the baby to pass through the birth canal. The first stage is further divided into early labor (0-4 cm dilation) and active labor (4-10 cm dilation). It is crucial for monitoring progress and determining when to move to the next stage of labor. The other choices are incorrect because the second stage is characterized by pushing and delivery of the baby, the third stage is delivery of the placenta, and the fourth stage is the postpartum period immediately after delivery.
Which hormone is responsible for stimulating milk production in the breasts?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: C
Rationale: The correct answer is C: Prolactin. Prolactin is the hormone responsible for stimulating milk production in the breasts. It is produced by the pituitary gland and plays a crucial role in lactation. Progesterone and estrogen are involved in preparing the breasts for milk production but do not directly stimulate it. Oxytocin is responsible for the ejection of milk from the breast but not for its production.
What is the recommended method of administering vitamin K to a newborn?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: A
Rationale: The correct method is A: Intramuscular injection. This route ensures rapid and reliable absorption of vitamin K, crucial for preventing bleeding disorders in newborns. Oral administration may be less effective due to variable absorption. Topical application is not recommended as it may not provide sufficient absorption. Subcutaneous injection can lead to variable absorption rates and is not as reliable as the intramuscular route for vitamin K administration.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Findings indicating improvement: Fundus at umbilicus, Moderate lochia rubra, Fundus firm to palpation Findings indicating worsening: Blood pressure 80/50 mm Hg, Thready pulse Unrelated finding: Cloudy urine Clinical Implication: The nurse should urgently address the low blood pressure and thready pulse, as they indicate ongoing hemodynamic instability due to postpartum hemorrhage. Immediate interventions such as IV fluids, blood transfusion, and further uterotonic medications may be necessary.