Nokea
The nurse is caring for a neonate shortly after birth when the neonate is diagnosed with sepsis and is to be treated with intravenous antibiotics. Which of the following should the nurse instruct the parents to do because of the neonate's infection?
- A. Use caution near the isolation incubator and equipment.
- B. Visit but do not touch the neonate.
- C. Wash their hands thoroughly before touching the neonate.
- D. Wear a mask when holding the neonate.
Correct Answer: C
Rationale: Thorough hand washing is critical to prevent further infection in a neonate with sepsis.
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I.V. oxytocin.png
- A. Continue to observe the fetal monitor.
- B. Anticipate rupture of the membranes.
- C. Prepare for fetal oximetry.
- D. Discontinue the Pitocin infusion.
Correct Answer: D
Rationale: Oxytocin (Pitocin) stimulates uterine contractions. If it causes excessive uterine activity (e.g., more than 5 contractions in 10 minutes or contractions lasting longer than 90 seconds), it can reduce placental perfusion
When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse record to do first?
- A. Weigh the neonate.
- B. Insert an orogastric tube.
- C. Prepare for immediate blood transfusion.
- D. Cover the abdomen with a moistened sterile gauze.
Correct Answer: D
Rationale: Covering the abdomen with moistened sterile gauze prevents infection and dehydration of the exposed intestines, which is the first priority.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
A primigravid client in active labor with a fetus in LOP position complains of severe back pressure. Which of the following would be the priority nursing diagnosis for this client?
- A. Anxiety related to fear of maternal-fetal outcomes.
- B. Ineffective coping related to lack of experience in labor.
- C. Urinary retention related to prolonged labor process.
- D. Pain related to occipitoposterior position and prolonged fetal descent.
Correct Answer: D
Rationale: Severe back pain due to the LOP position is a priority, as it impacts the client's comfort and labor experience. Pain management (e.g., counterpressure) is critical. Anxiety, coping, and urinary retention are secondary concerns.
A multiparous client, 28 hours after cesarean delivery, who is breast-feeding complains of severe cramps or afterpains. The nurse explains that these are caused by which of the following?
- A. Flatulence accumulation after a cesarean delivery.
- B. Healing of the abdominal incision after cesarean delivery.
- C. Adverse effects of the medications administered after delivery.
- D. Release of oxytocin during the breast-feeding session.
Correct Answer: D
Rationale: Breastfeeding stimulates oxytocin release, causing uterine contractions (afterpains) as the uterus involutes.