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During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.
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History and Physical:
Nurses' Notes:
Vital Signs:
Laboratory Results:
The client is a 28-year-old primiparous female who was induced at 41 weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock.
A nurse is caring for a primiparous client in the postpartum unit. The client was induced at 41 weeks gestation with misoprostol and oxytocin and gave birth vaginally 4 days ago. She was discharged home on day two with her newborn and has been breastfeeding around the clock. She called her healthcare provider this morning with fatigue, new-onset headache, nausea, dizziness, weakness, and seeing "flashing lights."
The nurse reviews the client's history, physical, and flow sheet to determine the cause of the client's symptoms. Highlight the information from the history, physical, and flow sheet that require further evaluation. Select all that apply.
- A. Hemoglobin 10.4 g/dL (6.45 mmol/L)
- B. Platelets 150,000/mm³ (150 x 10â¹/L)
- C. New-onset headache
- D. Vomiting small amount of yellow fluid
- E. Right upper quadrant pain
- F. Seeing flashing lights
- G. Elevated blood pressure
Correct Answer: C,D,E,F,G
Rationale: Headache, vomiting, right upper quadrant pain, flashing lights, and elevated blood pressure suggest postpartum preeclampsia or HELLP syndrome, requiring urgent evaluation.
A nurse is conducting a preconception class for a group of parents who are anticipating having children. Which client(s) should the nurse refer for genetic counseling? (Select all that apply)
- A. A couple who express concern about birth defects after using an internet DNA testing site.
- B. A woman and her significant other who are excited about the prospect of having children.
- C. A woman planning to start a second family after the loss of an embryo following an in-vitro fertilization procedure.
- D. A man who states that his father was recently diagnosed with Huntington's disease.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: A,C,D,E
Rationale: Concerns about birth defects, embryo loss, Huntington's disease, and donor sperm use indicate potential genetic risks requiring counseling, unlike general excitement about having children.
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation. Based on the client's symptoms, the nurse determines additional assessments are needed. Select the 4 assessments the nurse should perform.
- A. Fingerstick hemoglobin.
- B. Urine for protein.
- C. Perineal assessment.
- D. Vision test.
- E. Skin turgor.
- F. Deep tendon reflexes.
- G. Lung sounds.
Correct Answer: B,D,F,G
Rationale: Urine protein, vision test, deep tendon reflexes, and lung sounds assess preeclampsia indicators like proteinuria, visual disturbances, CNS irritability, and pulmonary edema.
One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell (WBC) count is 15,000/mm³ (15 x 10â¹/L). Which action should the nurse take first?
- A. Check the differential, since the WBC is normal for this client.
- B. Assess the client's perineal area for signs of a perineal hematoma.
- C. Assess the client's temperature, heart rate, and respirations every 4 hours.
- D. Notify the healthcare provider (HCP), since this finding is indicative of infection.
Correct Answer: A
Rationale: A WBC count of 15,000/mm³ is normal postpartum due to physiological stress; checking the differential confirms this, avoiding unnecessary interventions.
The day shift nurse reviews the nurse's notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge health teaching. For each teaching point, indicate whether it is Indicated (appropriate or necessary) or Contraindicated (could be harmful). Each box must have one option selected.
- A. You will need to set up an appointment with your pediatrician for 3 weeks from discharge.
- B. The discharge planning nurse will set up home bilirubin lights for you to use until you see the pediatrician.
- C. You will need to set up an appointment with your obstetrician in 8 weeks.
Correct Answer: A,B,C
Rationale: A: Indicated - Pediatric check-ups at 2-4 weeks monitor newborn health. B: Indicated - Bilirubin lights treat jaundice, preventing complications. C: Contraindicated - Obstetrician visits are typically at 6 weeks, not 8.