Nokea
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: Decreased temperature, lethargy, poor feeding, and respiratory distress are consistent with sepsis. Yellow sclera and oral mucosa are consistent with hyperbilirubinemia.
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Which of the following is a potential cause of recurrent pregnancy loss?
- A. Chromosomal abnormalities
- B. Immunologic factors
- C. Environmental factors
- D. All of the above
Correct Answer: D
Rationale: Recurrent pregnancy loss can be caused by chromosomal abnormalities, immunologic factors, or environmental factors.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health department.
Correct Answer: C
Rationale: The correct answer is C: Tell the client they will start medication for HIV immediately after delivery. This is because starting HIV medication immediately after delivery helps prevent vertical transmission of the virus to the baby. Administering penicillin G (choice A) is not indicated for HIV treatment. Instructing the client to schedule an annual pelvic examination (choice B) is important but not the priority in this case. Reporting the client's condition to the local health department (choice D) may be necessary for public health surveillance, but it is not the immediate action required for the client's care in this situation.
A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This is a concerning symptom that could indicate a serious condition like preeclampsia, which can be life-threatening for both the mother and the baby. Headaches that are severe and persistent, especially when accompanied by other symptoms like visual disturbances and high blood pressure, should be reported promptly.
Shortness of breath when climbing stairs (A) is common in late pregnancy due to the growing uterus pressing on the diaphragm. Swelling of feet and ankles (B) is also common in pregnancy and usually not a cause for concern unless it is sudden, severe, or accompanied by other symptoms. Braxton Hicks contractions (D) are normal practice contractions that do not indicate labor unless they become regular and intense.
Which stage of labor is characterized by the period between full cervical dilation and delivery of the fetus?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: B
Rationale: The second stage of labor begins with full cervical dilation and ends with the delivery of the fetus.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C: Remove all clothing from the newborn except the diaper. During phototherapy, the newborn's skin needs to be exposed to the light to effectively treat hyperbilirubinemia. Removing all clothing allows maximum skin exposure. Option A is incorrect as water does not help with phototherapy. Option B is incorrect as lotion can interfere with the effectiveness of the therapy. Option D is incorrect as a rash is a common side effect of phototherapy and discontinuing it would hinder treatment.