Nokea
The nurse is caring for a primiparous client and her neonate immediately after delivery. The neonate was born at 41 weeks' gestation and weighs 4,082 g (9 lb). Assessing for signs and symptoms of which of the following conditions should be a priority in the neonate?
- A. Anemia.
- B. Hypoglycemia.
- C. Delayed meconium.
- D. Elevated bilirubin.
Correct Answer: B
Rationale: Large-for-gestational-age neonates (e.g., 4,082 g) are at risk for hypoglycemia due to increased metabolic demand and potential maternal diabetes. Hypoglycemia screening is a priority. Anemia, delayed meconium, or hyperbilirubinemia are less immediate.
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Assessment reveals that the fetus of a multigravid client is at +1 station and 8 cm dilated. Based on these data, the nurse should first:
- A. Ask anesthesia to increase epidural rate.
- B. Assist the client to push if she feels the need to do so.
- C. Encourage the client to breathe through the urge to push.
- D. Support family members in providing comfort measures.
Correct Answer: C
Rationale: At 8 cm dilation and +1 station, the client is in the transition phase but not fully dilated (10 cm). Pushing before full dilation can lead to cervical edema or lacerations. Encouraging the client to breathe through the urge to push helps prevent premature pushing while supporting labor progression. Increasing the epidural rate or assisting with pushing is inappropriate at this stage, and while family support is valuable, it is not the priority.
The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal delivery. The nurse should next:
- A. Apply an ice pack to the perineal area.
- B. Assess the client's temperature.
- C. Have the client take a warm sitz bath.
- D. Contact the physician for orders for an antibiotic.
Correct Answer: A
Rationale: Applying an ice pack reduces swelling and bruising in the perineal area, which is appropriate for the described symptoms.
A multigravid client in active labor at term suddenly sits up and says, 'I can't breathe! My chest hurts really bad!' The client's skin begins to turn a dusky gray color. After calling for assistance, which of the following should the nurse do next?
- A. Administer oxygen by face mask.
- B. Begin cardiopulmonary resuscitation.
- C. Administer intravenous oxytocin.
- D. Obtain an order for intravenous fibrinogen.
Correct Answer: A
Rationale: Sudden dyspnea, chest pain, and dusky skin suggest a possible pulmonary embolism or amniotic fluid embolism. Administering oxygen improves oxygenation while awaiting further intervention. CPR is premature, oxytocin is irrelevant, and fibrinogen is for coagulopathy.
Which of the following indicates successful latch-on during a breast-feeding session?
- A. Neonate's lips are flanged outward.
- B. Mother reports sharp pain throughout feeding.
- C. Neonate's cheeks are dimpled.
- D. Mother hears clicking sounds during sucking.
Correct Answer: A
Rationale: Flanged lips indicate a proper latch, ensuring effective milk transfer and preventing nipple trauma.
The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients first?
- A. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes.
- B. A newborn delivered at 36-weeks' gestation weighing $5 \mathrm{lb}$ who is due to breast-feed for the first time in 15 minutes.
- C. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago.
- D. A newborn who had a borderline low temperature and was double-wrapped with a hat on ½ hour ago to bring up the temperature.
Correct Answer: C
Rationale: A respiratory rate of 62 is elevated and may indicate respiratory distress, requiring immediate assessment.