Nokea
The nurse is caring for a neonate at 38 weeks' gestation when the nurse observes marked peristaltic waves on the neonate's abdomen. After this observation, the neonate exhibits projectile vomiting. The nurse notifies the pediatrician because these signs are indicative of which of the following?
- A. Esophageal atresia.
- B. Pyloric stenosis.
- C. Diaphragmatic hernia.
- D. Hiatal hernia.
Correct Answer: B
Rationale: Marked peristaltic waves and projectile vomiting are classic signs of pyloric stenosis, a condition involving hypertrophy of the pylorus muscle.
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After teaching a multiparous client about the effects of hemolysis due to Rh sensitization on the neonate at delivery, the nurse determines that the client needs further instruction when the mother reports that the neonate may have which of the following?
- A. Cardiac decompensation.
- B. Polycythemia.
- C. Splenomegaly.
- D. Reduced bilirubin levels.
Correct Answer: D
Rationale: Hemolysis due to Rh sensitization causes increased bilirubin levels, not reduced levels, indicating a need for further instruction.
At 32 weeks' gestation, a 15-year-old primigravid client who is 5 feet, 2 inches tall has gained a total of 20 lb, with a 1-lb gain in the last 2 weeks. Urinalysis reveals negative glucose and a trace of protein. The nurse should advise the client that which of the following factors increases her risk for preeclampsia?
- A. Total weight gain.
- B. Short stature.
- C. Adolescent age group.
- D. Proteinuria.
Correct Answer: C
Rationale: Adolescents are at higher risk for preeclampsia due to incomplete physical maturity.
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.
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.
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which of the following behaviors during this phase of labor?
- A. Excitement.
- B. Loss of control.
- C. Numbness of the legs.
- D. Feelings of relief.
Correct Answer: B
Rationale: During the transition phase (8–10 cm dilation), primigravid clients without analgesia often experience intense contractions and may feel overwhelmed, leading to a perceived loss of control. Excitement is more common in early labor, numbness of the legs is associated with epidural anesthesia, and feelings of relief typically occur after delivery.