Nokea
Select the 3 findings that require immediate follow-up.
- A. Lateral deviation of the uterus
- B. Deep tendon reflexes 1+
- C. Pain rating of 3 on a scale of 0 to 10 (increased)
- D. Peripheral edema 2+ bilateral lower extremities
- E. Uterine tone soft
- F. Large amount of lochia rubra
- G. Blood pressure 136/86 mm Hg
Correct Answer: A,B,C,G
Rationale: These findings suggest uterine atony and bladder distention, which can lead to postpartum hemorrhage, a life-threatening emergency. Immediate interventions include fundal massage, bladder emptying, and administration of uterotonic medications.
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A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: A urine output of 280 mL within 8 hours is low and may indicate dehydration, which is a concern in a client with hyperemesis gravidarum.
What is the recommended method of administering the first dose of hepatitis B vaccine to a newborn?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: A
Rationale: The correct answer is A: Intramuscular injection. Administering the hepatitis B vaccine via intramuscular injection ensures proper absorption and immune response. Muscle tissue has a rich blood supply which aids in the rapid dissemination of the vaccine components throughout the body. This method also reduces the risk of injection site reactions. Oral administration (B) is not recommended for the hepatitis B vaccine as it may not provide sufficient immune response. Topical application (C) and subcutaneous injection (D) are not appropriate due to inadequate absorption and immunogenic response.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is A: Assist the client to ambulate to the bathroom. This action helps in promoting normal voiding patterns post-cesarean birth. Ambulation can aid in relieving pressure on the bladder, stimulating the urge to urinate, and facilitating the flow of urine. It also promotes circulation, which can help in reducing the risk of urinary retention.
Choice B: Inserting an indwelling urinary catheter should not be the initial intervention as it carries a risk of introducing infection and may not be necessary at this point.
Choice C: Performing a bladder scan can be considered if the client is unable to void after ambulation and other interventions have been attempted.
Choice D: Administering a diuretic is not appropriate in this situation as the client is experiencing difficulty in urinating rather than retaining excessive urine.
In summary, assisting the client to ambulate to the bathroom is the most appropriate initial action to address the client's complaint and promote normal voiding.
Which of the following is a potential complication of placenta previa?
- A. Preterm labor
- B. Fetal growth restriction
- C. Placental abruption
- D. All of the above
Correct Answer: C
Rationale: Placenta previa can lead to placental abruption, a serious condition where the placenta detaches from the uterine wall prematurely.
Which of the following is a potential ethical issue in maternal and newborn healthcare?
- A. Informed consent
- B. Patient confidentiality
- C. End-of-life decision-making
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. In maternal and newborn healthcare, ethical issues can arise in various aspects such as obtaining informed consent for procedures, ensuring patient confidentiality, and making difficult end-of-life decisions. Informed consent is crucial to respect patient autonomy. Patient confidentiality is vital to maintain trust and privacy. End-of-life decision-making involves complex ethical considerations. Choosing D is correct as all these issues are potential ethical concerns in this specific healthcare context. Choices A, B, and C alone are not comprehensive enough to cover the range of ethical issues that can arise in maternal and newborn healthcare.