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The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Findings indicating improvement: Fundus at umbilicus, Moderate lochia rubra, Fundus firm to palpation Findings indicating worsening: Blood pressure 80/50 mm Hg, Thready pulse Unrelated finding: Cloudy urine Clinical Implication: The nurse should urgently address the low blood pressure and thready pulse, as they indicate ongoing hemodynamic instability due to postpartum hemorrhage. Immediate interventions such as IV fluids, blood transfusion, and further uterotonic medications may be necessary.
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A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: Temperature is a priority assessment after an amniotomy, as it can indicate the onset of infection, such as chorioamnionitis.
Which of the following is a potential ethical issue related to neonatal organ donation?
- A. Informed consent
- B. Allocation of resources
- C. End-of-life decision making
- D. All of the above
Correct Answer: A
Rationale: Informed consent is a key ethical issue in neonatal organ donation.
Which of the following is a potential complication of a cesarean delivery?
- A. Postpartum hemorrhage
- B. Infection
- C. Deep vein thrombosis (DVT)
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Postpartum hemorrhage can occur due to surgical trauma, infection can develop at the incision site, and deep vein thrombosis (DVT) can result from immobility post-surgery. Choosing A, B, or C alone would be incorrect as cesarean delivery carries risks of all these complications. Selecting E, F, or G is incorrect due to lack of relevance to cesarean delivery complications.
What is the primary ethical principle guiding nursing practice in maternal and newborn healthcare?
- A. Autonomy
- B. Non-maleficence
- C. Beneficence
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Beneficence. In maternal and newborn healthcare, beneficence is the primary ethical principle guiding nursing practice. This principle emphasizes the nurse's duty to promote the well-being and best interests of both the mother and the newborn. Nurses must act in a way that benefits their patients and ensures their safety and health. Autonomy (A) focuses on respecting the patient's right to make their own decisions, which is important but not the primary principle in this context. Non-maleficence (B) involves avoiding harm, which is essential but not the primary guiding principle here. Justice (D) pertains to fairness in healthcare access and resource allocation, which is also crucial but not the primary ethical principle for maternal and newborn healthcare.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: Substernal retractions are a sign of respiratory distress in newborns and require immediate medical attention to ensure proper oxygenation.