Nokea
The nurse is preparing a client for a postpartum tubal ligation. What is the priority preoperative nursing action?
- A. Insert an indwelling catheter.
- B. Verify signed informed consent.
- C. Administer prescribed antibiotics.
- D. Check for maternal vital signs.
Correct Answer: B
Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.
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Which will indicate a concealed hemorrhage in an abruptio placenta?
- A. Hard board-like abdomen
- B. Decreased fundal height
- C. Bradycardia
- D. Decreased abdominal pain
Correct Answer: A
Rationale: A concealed hemorrhage in abruptio placentae, also known as a concealed retroplacental hematoma, can cause rapid, significant bleeding behind the placenta with limited visible external bleeding. This internal bleeding can lead to significant blood loss and can cause the uterus to become tense and firm, resulting in a hard board-like abdomen upon palpation. This clinical sign is a key indicator of a concealed hemorrhage in abruptio placentae and should prompt immediate medical attention to prevent maternal and fetal complications. The other choices, such as decreased fundal height, bradycardia, and decreased abdominal pain, are not typically associated with a concealed hemorrhage in abruptio placentae.
The nurse is reviewing the role of the placenta in fetal development. Which statement should be included?
- A. The placenta stores nutrients for the fetus.
- B. The placenta prevents all infections from reaching the fetus.
- C. The placenta transfers oxygen and nutrients to the fetus.
- D. The placenta produces progesterone only in early pregnancy.
Correct Answer: C
Rationale: The placenta facilitates the transfer of oxygen and nutrients while removing waste products.
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance ... that crosses the suture line. The nurse should identify the swellings as which of the following....?
- A. Nevus flammeus
- B. Caput uccedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: C
Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.
Which action is the most appropriate nursing measure when a baby has an unexpected defect at birth?
- A. Remove the baby from the delivery area immediately.
- B. Inform the parents immediately that something is wrong.
- C. Tell the parents that the baby has to go to the nursery immediately.
- D. Explain the defect and show the baby to the parents as soon as possible.
Correct Answer: D
Rationale: When a baby is born with an unexpected defect, it is crucial for the nursing staff to explain the defect to the parents and show the baby to them as soon as possible. This approach allows for open communication, transparency, and the opportunity for the parents to start processing the situation emotionally. By involving the parents and keeping them informed, trust and understanding can be established between the healthcare providers and the family, ultimately fostering a supportive environment for everyone involved in the care of the baby. It is essential to approach the situation with empathy and sensitivity while providing the necessary information to the parents.
A delivering patient presses the call light and reports that her water just broke the nurse first action should be:
- A. Check the fetal heart tone
- B. Call physician
- C. Change bed linen
- D. Encourage mother to go for a walk
Correct Answer: A
Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.