Nokea
The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby who exhibited visible birth defects. Which of the following actions by the nurse is appropriate?
- A. Discourage the parents from naming the baby.
- B. Advise the parents that the baby's defects would be too upsetting for them to see.
- C. Transport the baby to the morgue as soon as possible.
- D. Give the parents a lock of the baby's hair and a copy of the footprint sheet.
Correct Answer: D
Rationale: Providing keepsakes helps with grieving.
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A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action?
- A. Postpartum hemorrhage.
- B. Severe postural headache.
- C. Pruritic skin rash.
- D. Paralytic ileus.
Correct Answer: B
Rationale: High Fowler's position increases the risk of postural headaches.
A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time?
- A. Reglan (metoclopramide).
- B. Demerol (meperidine).
- C. Seconal (secobarbital).
- D. Benadryl (diphenhydramine).
Correct Answer: A
Rationale: Reglan treats nausea.
A mother is told that she should bottle feed her child for medical reasons. Which of the following maternal disease states are consistent with the recommendation? Select all that apply.
- A. Untreated
- B. active tuberculosis.
- C. Hepatitis B surface antigen positive.
- D. Human immunodeficiency virus positive.
Correct Answer: A
Rationale: Breastfeeding is contraindicated in untreated TB and HIV.
A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select one that doesn't apply
- A. G1 P0000, delivered a fetal demise at 29 weeks' gestation.
- B. G2 P1001, prolonged first stage of labor.
- C. G2 P0010, delivered by cesarean section for failure to progress.
- D. G3 P0200, delivered vaginally a 42-week, 2,200-gram neonate.
Correct Answer: D
Rationale: These scenarios increase hemorrhage risk.
If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
- A. No specific instructions
- B. Drinking plenty of fluids to prevent fever
- C. Recommendation to stop breastfeeding for 24 hours after the injection
- D. Explanation of the risks of becoming pregnant within 28 days following injection
Correct Answer: D
Rationale: The correct answer is D because the rubella vaccine contains live virus and poses a risk to the fetus if the patient becomes pregnant within 28 days of receiving the vaccine. Providing instructions about the risks of pregnancy after vaccination is crucial to prevent potential harm to the fetus.
A: Incorrect - Specific instructions are necessary due to the live virus in the vaccine.
B: Incorrect - Drinking fluids does not address the specific risks associated with pregnancy after vaccination.
C: Incorrect - Stopping breastfeeding is not necessary after receiving the rubella vaccine.