Nokea
The nurse is assessing a multiparous client 12 hours after vaginal delivery. Which finding requires immediate intervention?
- A. Fundus firm, 1 cm above umbilicus.
- B. Lochia rubra with small clots.
- C. Perineal pain rated 3/10.
- D. Pulse 100 bpm, temperature 100.4°F (38°C).
Correct Answer: D
Rationale: An elevated pulse and temperature may indicate infection or hemorrhage, requiring prompt intervention.
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When reviewing the prenatal history for a newly delivered neonate, the nurse notes that the mother has neurofibromatosis. The nurse should further assess the neonate for:
- A. Caffé au lait spots.
- B. Port wine nevus.
- C. Strawberry hemangiomas.
Correct Answer: A
Rationale: Neurofibromatosis is associated with café au lait spots, which are a hallmark sign to assess in the neonate.
During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
- A. Wipe off any lanolin creams from the nipple before each feeding.
- B. Position the baby with the entire areola in the baby's mouth.
- C. Feed the baby less often for the next several days.
- D. Use a mild soap while in the shower to prevent an infection.
Correct Answer: B
Rationale: Proper positioning with the areola in the baby's mouth prevents and heals sore nipples.
Following an epidural and placement of internal monitors, a client's labor is augmented. Contractions are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting tone is greater than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
- A. Notify the health care provider.
- B. Turn off the oxytocin (Pitocin) infusion.
- C. Turn the client to her left side.
- D. Increase the maintenance I.V. fluids.
Correct Answer: B
Rationale: Hyperstimulation (contractions >90 seconds, frequent, with high resting tone) and nonreassuring fetal heart rate indicate fetal distress. Stopping oxytocin is the first step to reduce uterine activity and improve fetal oxygenation. Repositioning, notifying the provider, or increasing fluids follow.
A 39-year-old multigravid client asks the nurse for information about female sterilization with a tubal ligation. Which of the following client statements indicates effective teaching?
- A. My fallopian tubes will be tied off through a small abdominal incision.
- B. Reversal of a tubal ligation is easily done, with a subsequent pregnancy rate of 80%.
- C. The tubal ligation will decrease my risk of getting ovarian cancer.
- D. The tubal ligation will cause me to go through menopause earlier than usual.
Correct Answer: A
Rationale: Tubal ligation involves blocking or tying the fallopian tubes, often through a small abdominal incision. Reversal is complex with lower success rates, it does not significantly reduce ovarian cancer risk, and it does not affect menopause timing.
Which of the following statements by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?
- A. BPD is an acute disease that can be treated with antibiotics.'
- B. My baby may require permanent assisted ventilation.'
- C. Bronchodilators can cure my baby's condition.'
- D. My baby may have seizures later on in life because of this condition.'
Correct Answer: B
Rationale: BPD is a chronic lung condition that may require long-term respiratory support, including permanent assisted ventilation.