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
Rationale: The correct choices for immediate follow-up are A, B, and C. A lateral deviation of the uterus could indicate a possible complication like uterine atony or retained products of conception. Deep tendon reflexes of 1+ could suggest hyporeflexia or neurological issues. A pain rating of 3 on a scale of 0 to 10, especially if it has increased, may indicate worsening pain or a new issue. Choices D, E, F, and G do not present immediate concerns that require urgent follow-up compared to choices A, B, and C. Peripheral edema 2+ in bilateral lower extremities, soft uterine tone, large amount of lochia rubra, and a blood pressure of 136/86 mm Hg are important findings but do not necessitate immediate intervention or follow-up.
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A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. When a newborn is delivered with a nuchal cord (around the neck), it can cause pressure on the baby's face during delivery, leading to tiny broken blood vessels called petechiae. This is a common finding in newborns with nuchal cords due to the pressure exerted on the face. Telangiectatic nevi (A), periauricular papillomas (C), and erythema toxicum (D) are not typically associated with nuchal cords. Petechiae is the most likely finding in this scenario.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers to report to the provider are A, B, C, and G.
A: Coombs test result is crucial for diagnosing hemolytic anemia.
B: Mucous membrane assessment reflects hydration and oxygenation status.
C: Intake and output are vital for monitoring fluid balance.
G: Sclera color can indicate jaundice or liver dysfunction.
Other choices like D, E, and F are important assessments but not as critical for immediate provider notification. The respiratory rate (D) and heart rate (F) are essential vital signs but can be monitored routinely. Head assessment findings (E) can be important but may not require immediate provider notification unless there is a significant change.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: The correct answer is B: Assess the newborn's latch while breastfeeding. Sore nipples in breastfeeding mothers are often caused by improper latch. By assessing the newborn's latch, the nurse can identify any issues and provide guidance to the client on how to improve latch technique, which can alleviate nipple soreness. Waiting 4 hours between feedings (choice A) can lead to engorgement and decreased milk supply. Limiting breastfeeding time to 5 min per breast (choice C) can also affect milk supply. Offering supplemental formula (choice D) can interfere with establishing successful breastfeeding.
A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to their prolonged growth in utero. This is a common finding in babies born after 42 weeks gestation. Large deposits of subcutaneous fat (choice A) are typically seen in term or postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (choice B) is known as lanugo, which is present in premature infants, not postterm. Pale, translucent skin (choice D) is more common in premature infants, not postterm.
Which of the following assessment findings requires Immediate follow-up? Select all that apply,
- A. Platelet count
- B. Vaginal bleeding
- C. HCT
- D. RBC Count
- E. Fetal heart rate
- F. hgb
- G. WBC Count
Correct Answer: B,C,E,F
Rationale: The correct answers are B, C, E, and F. Vaginal bleeding requires immediate follow-up to assess for potential complications. HCT, HGB, and WBC count are crucial for evaluating maternal health. Fetal heart rate is essential for monitoring fetal well-being. Platelet count and RBC count are important but not as urgent as the other findings.