Nokea
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
- A. The eyes cross and uncross when they are open.
- B. The ears are positioned in alignment with the inner and outer canthus of the eyes.
- C. Axillae and femoral folds of the baby are covered with a white cheesy substance.
- D. The nostrils flare whenever the baby inhales.
Correct Answer: D
Rationale: Nostril flaring indicates respiratory distress.
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The nurse educates the non–breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: The correct answer is B: Apply cold packs and cabbage leaves. Engorgement causes breast swelling and discomfort due to increased blood and milk supply. Applying cold packs reduces inflammation and pain. Cabbage leaves have a cooling effect and can help reduce swelling. Massaging breasts can worsen engorgement by stimulating more milk production. Standing in a warm shower may provide temporary relief but does not address the root cause. Not wearing a bra may lead to discomfort and does not alleviate engorgement.
Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: The correct answer is B because avoiding holding the newborn is a sign of lack of attachment in postpartum persons. This behavior indicates a lack of desire or ability to bond with the newborn, which is crucial for healthy emotional development. Intense eye contact (choice A) and cuddling (choice C) are typically associated with bonding behaviors. Exploring the newborn (choice D) can also be a positive behavior showing interest. However, the key indicator of attachment issues is the avoidance of holding the newborn, making choice B the correct answer.
A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose?
- A. Vitamin K.
- B. Protamine.
- C. Vitamin E.
- D. Mannitol.
Correct Answer: B
Rationale: Protamine reverses heparin effects.
The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement?
- A. Maintain client in left lateral recumbent position.
- B. Teach sitz bath use on second postoperative day.
- C. Perform active range-of-motion exercises until ambulating.
- D. Assess central venous pressure during first postoperative day.
Correct Answer: B
Rationale: Sitz baths promote healing and comfort.
When assessing the A of the acronym REEDA, the nurse should evaluate the
- A. skin color.
- B. degree of edem
- C. edges of the episiotomy.
- D. episiotomy for discharg
Correct Answer: C
Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.