Nokea
The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
- A. Document the findings.
- B. Massage the uterine fundus until it is firm.
- C. Catheterize the client.
- D. Call the physician immediately.
Correct Answer: B
Rationale: Massaging the uterus helps to contract it and control postpartum bleeding, making it the first step in managing a boggy uterus.
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During an assessment of a 12-hour-old newborn, the nurse notices pale pink spots on the nape of the neck. How does the nurse document this finding?
- A. nevus vasculosus
- B. Mongolian spots
- C. nevus flammeus
- D. telangiectatic nevi
Correct Answer: C
Rationale: Nevus flammeus, also known as salmon patches, are common vascular markings often seen on the nape of the neck.
A postpartum nurse is giving guidance to a mother whose breast-fed newborn is experiencing hyperbilirubinemia. What are the best instructions for the nurse to give the mother in this case?
- A. It is best for the infant if she stops breast-feeding and switches to bottle-feeding permanently.
- B. The mother should switch to bottle-feeding until the baby’s bilirubin returns to normal range.
- C. The mother should alternate breast-feeding and bottle-feeding to ensure adequate fluid intake, until the baby’s bilirubin returns to normal range.
- D. The mother should continue to breast-feed the infant every 2 to 3 hours or more frequently as tolerated (every 2 hours if under phototherapy).
Correct Answer: D
Rationale: Continued frequent breastfeeding helps reduce bilirubin levels effectively.
The nurse is caring for a patient who has been diagnosed as having a fetal death. The nurse is aware of the possible causes of intrapartum fetal death. How can the nurse explain the potential causes of IPFD to the patient?
- A. We will always find the cause of fetal death with an autopsy.
- B. Infection is never a cause of fetal death.
- C. Umbilical cord entanglement can cause fetal death.
- D. Congenital anomalies cause growth restriction, not fetal death.
Correct Answer: C
Rationale: Umbilical cord entanglement is a recognized cause of intrapartum fetal death (IPFD). While congenital anomalies may lead to complications, they are not typically direct causes of IPFD. Infections can also contribute to fetal death, making option B incorrect. Autopsies help identify causes but do not guarantee definitive answers, so A is incorrect.
A newborn that is a large-for-gestational-age (LGA) infant is in which percentile(s) for weight?
- A. Below the 90th
- B. Less than the 10th
- C. Greater than the 90th
- D. Between the 10th and 90th
Correct Answer: C
Rationale: The correct answer is C because a newborn classified as large-for-gestational-age (LGA) is above the 90th percentile for weight based on their gestational age. This means the infant's weight is greater than 90% of other infants of the same gestational age. Choices A and B are incorrect as they indicate being below the 90th percentile, which is not the case for an LGA infant. Choice D is also incorrect as an LGA infant's weight is specifically above the 90th percentile, not between the 10th and 90th percentile.
An infant was born with anencephaly and was taken immediately to the NICU. The parents are about to visit for the first time. What action by the nurse is most appropriate?
- A. Call the hospital chaplain to visit the parents.
- B. Obtain informed consent for emergency surgery.
- C. Prepare the parents for how the infant will look.
- D. Show the parents proper gowning and gloving.
Correct Answer: C
Rationale: Infants born with anencephaly (incomplete closure of the anterior portion of the neural tube) are often missing parts of the brain, forehead, skull, and occiput. The nurse must be very sensitive in working with the parents of such children and needs to prepare the parents for how the child will look. Well-prepared parents have a better chance of being able to bond with their child. A visit from the chaplain may or may not be welcomed. Emergency surgery is not performed. Proper gowning and gloving are not needed unless the infant is in isolation.