Nokea
The day shift nurse reviews the nurse's notes, labs, and flow sheet from the night before. The nurse plans on providing health teaching for the client and her family in preparation for discharge health teaching. For each teaching point, indicate whether it is Indicated (appropriate or necessary) or Contraindicated (could be harmful). Each box must have one option selected.
- A. You will need to set up an appointment with your pediatrician for 3 weeks from discharge.
- B. The discharge planning nurse will set up home bilirubin lights for you to use until you see the pediatrician.
- C. You will need to set up an appointment with your obstetrician in 8 weeks.
Correct Answer: A,B,C
Rationale: A: Indicated - Pediatric check-ups at 2-4 weeks monitor newborn health. B: Indicated - Bilirubin lights treat jaundice, preventing complications. C: Contraindicated - Obstetrician visits are typically at 6 weeks, not 8.
You may also like to solve these questions
A new parent asks the nurse about an area of swelling on the baby's head near the posterior fontanel that lies across the suture line. How should the nurse respond?
- A. “That is called caput succedaneum. It will have to be drained.â€.
- B. “That is called a cephalhematoma. It can cause jaundice as it is absorbed.â€.
- C. “That is called a cephalhematoma. It will cause no problems.â€.
- D. “That is called caput succedaneum. It will absorb and cause no problems.â€.
- E. A couple who plan to use in-vitro fertilization with donated sperm.
Correct Answer: D
Rationale: Caput succedaneum is swelling across suture lines that resolves spontaneously, unlike cephalhematoma, which is confined and may cause jaundice.
At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Start prescribed IV with lactated Ringer's.
- B. Inform the anesthesia care provider.
- C. Ensure preoperative lab results are available.
- D. Contact the client's obstetrician.
Correct Answer: B
Rationale: Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first to manage potential complications like increased gastric acidity and delayed gastric emptying.
A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?
- A. Request placement of the epidural.
- B. Give a bolus of intravenous fluids.
- C. Decrease the oxytocin infusion rate.
- D. Determine current cervical dilation.
Correct Answer: D
Rationale: Assessing current cervical dilation ensures labor progress is suitable for epidural placement, preventing complications like slowed labor.
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.
A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.