Nokea
The nurse is caring for a postpartum client who reports feeling overwhelmed and tearful. What is the nurse's priority intervention?
- A. Administer a sedative as prescribed.
- B. Encourage the client to rest and sleep.
- C. Provide emotional support and reassurance.
- D. Refer the client to a mental health professional.
Correct Answer: C
Rationale: The correct answer is C: Provide emotional support and reassurance. This is the priority intervention because the client is feeling overwhelmed and tearful, indicating a need for immediate emotional support. Administering a sedative (A) may mask the underlying issue and is not addressing the client's emotional needs. Encouraging rest and sleep (B) is important but secondary to addressing the client's emotional state. Referring the client to a mental health professional (D) may be necessary in the long term but is not the immediate priority in this situation. Emotional support and reassurance can help the client feel validated and supported in the moment.
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Induction of labor is planned for 31-year-old primigravida 39 weeks. She has insulin dependent diabetes. Which nursing action is more important?
- A. Begin Pitocin 4h after Cytotec (thin the cervix first)
- B. Administer 100mcg Cytotec q2h(no)
- C. Place vaginal gel and ambulate patient 1h
- D. Prepare to induce labor after administering tap water enema
Correct Answer: A
Rationale: The correct answer is A: Begin Pitocin 4h after Cytotec. This is the most important nursing action because it follows the recommended protocol for inducing labor in a diabetic patient. Cytotec is used to thin the cervix, and waiting 4 hours before starting Pitocin reduces the risk of uterine hyperstimulation, which can be dangerous for the mother and baby. Administering Cytotec every 2 hours (choice B) can increase the risk of hyperstimulation. Placing vaginal gel and ambulating the patient (choice C) may not be appropriate in this case as the patient has diabetes. Preparing to induce labor after administering a tap water enema (choice D) is not a priority compared to ensuring a safe induction process for a diabetic patient.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn's mother asks about the swollen area on her son's head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. "Mongolian spots can be found on the skin of many newborns."
- B. "A caput succedaneum occurs due to compression of blood vessels."
- C. "This is a cephalhematoma, which can occur spontaneously."
- D. "This is erythema toxicum, which is a transient condition."
Correct Answer: C
Rationale: The correct answer is C: "This is a cephalhematoma, which can occur spontaneously."
1. Cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines and is due to trauma during delivery.
2. Caput succedaneum (choice B) occurs due to pressure during labor and resolves within a few days.
3. Mongolian spots (choice A) are benign bluish-grey birthmarks commonly found in newborns and are not related to head swelling.
4. Erythema toxicum (choice D) is a common rash in newborns, not related to head swelling.
In summary, the correct choice is C because it accurately describes the condition observed in the newborn after vacuum-assisted delivery.
What is the priority nursing care associated with oxytocin infusion?
- A. Monitoring uterine response (don't want it to ruptur
- C. Measuring urinary output
- D. Check cervical dilation
Correct Answer: A
Rationale: The correct answer is A because monitoring uterine response is crucial when administering oxytocin infusion to prevent uterine hyperstimulation and rupture. This involves assessing contraction frequency, duration, and strength. Measuring urinary output (choice C) is important for overall fluid balance but not directly related to oxytocin infusion. Checking cervical dilation (choice D) is not a priority when administering oxytocin. Choice B is incomplete.
The nurse is assessing a postpartum client. Which finding requires immediate intervention?
- A. Fundus firm and midline.
- B. Lochia rubra with large clots.
- C. Mild swelling in the perineal area.
- D. Breast tenderness on day 2 postpartum.
Correct Answer: B
Rationale: The correct answer is B because Lochia rubra with large clots could indicate excessive bleeding, which is a postpartum hemorrhage and requires immediate intervention to prevent further complications. A: Fundus firm and midline is a normal finding. C: Mild swelling in the perineal area is expected after childbirth. D: Breast tenderness on day 2 postpartum is a common finding due to milk production starting.
In what stage does the corpus luteum form?
- A. Luteal phase
- B. Follicular phase
- C. Proliferative phase
- D. Shedding of endometrium phase
Correct Answer: A
Rationale: The corpus luteum forms during the luteal phase of the menstrual cycle. After ovulation, the ruptured follicle transforms into the corpus luteum, which secretes progesterone to prepare the uterus for potential pregnancy. If fertilization doesn't occur, the corpus luteum degenerates, leading to a drop in progesterone levels and the start of menstruation. The other choices, such as the follicular phase (B) where the follicles develop, proliferative phase (C) where the endometrium thickens, and shedding of endometrium phase (D) where menstruation occurs, do not involve the formation of the corpus luteum.