Nokea
Which postpartum client requires further assessment?
- A. G1P1 with class II heart disease and complains of frequent coughing and has crackles
- B. G3P2 post c/s client who has active herpes on the labia
- C. G4P4 who had 4 saturated pads during the last 12 hours
- D. G2P2 diabetic whose fasting blood sugar is 100
Correct Answer: C
Rationale: The postpartum client who requires further assessment is the G4P4 who had 4 saturated pads during the last 12 hours. This indicates excessive postpartum bleeding, which is abnormal and could potentially be a sign of postpartum hemorrhage. It is crucial to closely monitor and assess the client's vital signs, uterine tone, and overall well-being to prevent any complications related to excessive bleeding. Prompt intervention and medical attention may be necessary to address the postpartum hemorrhage and ensure the client's safety and well-being.
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A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn's visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to addictive drugs in utero, commonly seen in infants born to mothers with substance use disorders. These babies often experience withdrawal symptoms such as tremors, irritability, and difficulty sleeping. Swaddling the newborn in a flexed position can help provide comfort and security to the infant, which may help alleviate some of the withdrawal symptoms they are experiencing. This intervention can also mimic the snug environment of the womb, promoting a sense of calmness for the newborn. It is important to create a soothing environment to aid in the management of NAS symptoms.
What is a common risk factor for breast cancer? Select all that apply.
- A. being assigned female at birth
- B. having a first-degree relative with breast cancer
- C. carrying mutations in BRCA1 and BRCA2 genes
- D. being of African American ethnicity
Correct Answer: A,B,C
Rationale:
The nurse is caring for a client who just had a cesarean delivery. What is the priority nursing action?
- A. Assess the surgical site.
- B. Monitor for signs of infection.
- C. Assess the uterine fundus for firmness.
- D. Encourage early ambulation.
Correct Answer: C
Rationale: Assessing fundal firmness helps detect uterine atony and prevent postpartum hemorrhage after delivery.
A patient with Type 1 Diabetes delivers a 9-pound 10 oz. baby by cesarian birth in her 36th week of pregnancy. When monitoring the infant of a mother with diabetes, the nurse should monitor for signs of:
- A. Meconium ileus
- B. Respiratory distress
- C. Physiologic jaundice
- D. Increased intracranial pressure
Correct Answer: B
Rationale: Infants of diabetic mothers are at increased risk for developing respiratory distress syndrome due to factors such as prematurity, intrauterine stress, and macrosomia (large birth weight). Additionally, babies born to mothers with diabetes may have delayed lung maturation, resulting in decreased surfactant production and increased risk of respiratory complications. Therefore, it is crucial for the nurse to monitor the infant for signs of respiratory distress, such as tachypnea, grunting, retractions, and cyanosis, and provide necessary interventions promptly.
What does the nurse know about the definition of a family?
- A. Families are made up of couples with biological children.
- B. Families are created through marriage or birth.
- C. Families can be blended but are not called families.
- D. Families are made of kinships defined by the family.
Correct Answer: D
Rationale: Families are diverse and defined by the individuals involved, not limited to traditional structures.