Nokea
The nurse assess that a newborn is in respiratory distress when the infant exhibits:
- A. Apnea, grunting, wheezing, and crackles
- B. Wheezing, cyanosis, hiccups, and crackles
- C. Cyanosis, retraction, wheezing, and hiccups
- D. Tachypnea, retraction, grunting, and cyanosis
Correct Answer: D
Rationale: In newborns, respiratory distress can present with various signs and symptoms. The combination of tachypnea (rapid breathing), chest retractions (visible sinking of the skin in between or below the ribs with each breath), grunting (sound made during expiration), and cyanosis (blue discoloration of the skin and mucous membranes) are indicative of respiratory distress in a newborn. These signs suggest that the newborn is having difficulty breathing and may require immediate medical attention. It is essential to recognize and address respiratory distress promptly to ensure the well-being of the newborn.
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The nurse is assessing a client with suspected ectopic pregnancy. What is the most common symptom?
- A. Bright red vaginal bleeding.
- B. Severe lower abdominal pain.
- C. Increased fetal movement.
- D. Painless vaginal spotting.
Correct Answer: B
Rationale: Severe lower abdominal pain, often on one side, is a hallmark symptom of ectopic pregnancy.
A woman delivered a baby 9lbs 10oz 1 hour ago. When you
arrive to perform a 15-minute assessment she tells you that she feels
all wet underneath. You discover that both pads are completely
saturated and that she’s lying in a 6-inch diameter of blood. What
does nurse do first
- A. Assess the fundus for firmness
- B. Change the patient's pads
- C. Notify the provider
- D. Document the findings
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse to take is to assess the source of the woman's feeling of wetness underneath her. This could indicate a significant amount of postpartum bleeding, also known as hemorrhage. It is crucial to determine if she is experiencing excessive bleeding as this can be life-threatening if not addressed promptly. By identifying the source of the wetness, the nurse can assess the situation and take appropriate actions to address any potential complications. Once the severity of bleeding is determined, further assessments and interventions can be initiated accordingly.
The nurse is attempting to explain physiologic birth. What do they say?
- A. Physiologic birth involves interventions that do not harm the baby.â€
- B. Physiologic birth occurs only in birth centers.â€
- C. If your partner and I give you support, you can have a birth without medical intervention.â€
- D. If you want to have a cesarean birth, we can ask your health-care provider to schedule it.â€
Correct Answer: C
Rationale: Physiologic birth focuses on minimal intervention, supported by a calm environment and supportive care.
The nurse is teaching a client about signs of preterm labor. Which symptom should be reported immediately?
- A. Increased fetal movements.
- B. Lower back pain and cramping.
- C. Mild swelling of the feet.
- D. Occasional Braxton Hicks contractions.
Correct Answer: B
Rationale: Lower back pain and cramping may indicate preterm labor and should be reported promptly.
A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
- A. A client who has an ultrasound that confirms a molar pregnancy
- B. A client who has a crown-rump length of 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct Answer: B
Rationale: The nurse should auscultate the fetal heart rate during the prenatal visit for the client who has a crown-rump length of 7 weeks gestation. At this stage, the fetal heart is usually visible on ultrasound, and auscultating the fetal heart rate can provide valuable information about the health and development of the fetus. It is an important part of prenatal care to monitor the fetal heart rate regularly to ensure the well-being of the baby. In the other scenarios provided: