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The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
- A. Administer a PRN dose of acetaminophen.
- B. Assess perineum for excessive lochia.
- C. Document the vital signs in the record.
- D. Report heart rate to healthcare provider.
Correct Answer: C
Rationale: These vital signs are normal postpartum; documenting them ensures accurate tracking without unnecessary interventions.
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The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?
- A. Offer a pacifier dipped in glucose water.
- B. Give a PRN dose of liquid acetaminophen.
- C. Place petrolatum gauze dressings on the site.
- D. Wrap the infant in warm receiving blankets.
Correct Answer: C
Rationale: Petrolatum gauze prevents wound adherence to diapers, reducing irritation and infection risk, prioritizing post-circumcision care.
During a routine prenatal visit, a client at 32-weeks gestation reports that urinary frequency has increased during the day as well as at night. The nurse determines the client is having irregular uterine contractions. Which action should the nurse implement?
- A. Collect a urine sample for dipstick analysis.
- B. Ask the client if she had sexual intercourse yesterday.
- C. Obtain a midstream urine specimen for culture.
- D. Determine if she has a change in vaginal discharge.
Correct Answer: C
Rationale: A midstream urine culture diagnoses UTIs, which can cause urinary frequency and uterine irritability, guiding targeted treatment.
The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?
- A. Seizures.
- B. Stroke.
- C. Organ damage.
- D. Preterm birth.
Correct Answer: A,B,C,D
Rationale: Preeclampsia increases risks of seizures (eclampsia), stroke, organ damage (liver/kidneys), and preterm birth due to placental insufficiency.
When is the best time to administer a rubella vaccine to a client?
- A. After the client reaches 20-weeks gestation.
- B. Immediately, at 6-weeks gestation, to protect this fetus.
- C. Early postpartum, within 72 hours after delivery.
- D. After the client stops breastfeeding.
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
The nurse is reviewing laboratory results and nurse's notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)
- A. Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.
- B. Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).
- C. Monitor temperature.
- D. Continue to monitor glucose levels.
- E. Explain to the mother that the baby's respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.
- F. Tell the mother that she will need to discuss any concerns with the neonatologist.
- G. Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.
Correct Answer: A,B,C,D
Rationale: Monitoring respiratory distress, temperature, and glucose levels ensures newborn stability, while bilirubin lights treat jaundice, addressing critical neonatal needs.