Nokea
Which of the following findings would indicate
- A. Reversal of a tubal ligation is easily done, with a an infant who may be considered preterm?
- B. Labia minora are larger than labia majora
- C. After this procedure, I must abstain from inter-
- D. Plantar creases cover two-thirds of foot
Correct Answer: D
Rationale: The correct answer is D because plantar creases covering two-thirds of the foot is a typical finding in Down syndrome. This is known as the Sandal gap sign, which is a characteristic feature of Down syndrome. The other choices are incorrect because: A is not related to any specific medical condition, B describes a normal anatomical variation, and C is incomplete and does not provide enough information to determine its relevance.
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The nurse is preparing a postpartum client for discharge. Which instruction is most important?
- A. Avoid breastfeeding if you feel tired.
- B. Report foul-smelling lochia to your doctor.
- C. Resume all physical activity immediately.
- D. Stop taking your prenatal vitamins after discharge.
Correct Answer: B
Rationale: The correct answer is B: Report foul-smelling lochia to your doctor. This instruction is crucial because foul-smelling lochia can indicate an infection, which requires immediate medical attention to prevent complications. Reporting this to the doctor promptly ensures timely treatment.
A: Avoid breastfeeding if you feel tired - Incorrect. Breastfeeding is important for the baby's nutrition and bonding, regardless of the mother's fatigue.
C: Resume all physical activity immediately - Incorrect. Gradual resumption of physical activity is recommended to allow the body to heal properly.
D: Stop taking your prenatal vitamins after discharge - Incorrect. Prenatal vitamins are beneficial for postpartum recovery and breastfeeding, so stopping them abruptly is not advisable.
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.
Immediately after the forceps assists in the birth of an infant, what should the nurse do with the baby?
- A. Assess infant for signs of trauma
- B. Administer a vitamin K injection
- C. Provide immediate breastfeeding
- D. Monitor for signs of hypoglycemia
Correct Answer: A
Rationale: Rationale: Immediately after forceps-assisted birth, assessing the infant for signs of trauma is crucial for detecting any injuries or complications. This ensures prompt intervention if needed. Administering a vitamin K injection, providing immediate breastfeeding, and monitoring for hypoglycemia are important but secondary tasks that can be done after ensuring the infant's safety.
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.
How can a nurse reduce the risk of infection in a newborn in the NICU?
- A. Maintain strict hand hygiene
- B. Limit visitors and monitor closely for signs of infection
- C. Ensure proper sterilization of equipment
- D. Administer prophylactic antibiotics
Correct Answer: B
Rationale: Rationale for Correct Answer (B): Limiting visitors and monitoring closely for signs of infection in a newborn in the NICU is crucial because newborns are highly vulnerable to infections. By restricting visitors, the risk of introducing pathogens is reduced. Close monitoring allows for early detection of any signs of infection, enabling prompt intervention to prevent complications.
Summary of Other Choices:
A: While maintaining strict hand hygiene is important, it alone is not sufficient to reduce the risk of infection in a newborn in the NICU.
C: Proper sterilization of equipment is essential but may not directly address the risk of infection transmission from visitors or other sources.
D: Administering prophylactic antibiotics is not recommended as a routine measure due to the potential for antibiotic resistance and adverse effects in newborns. Monitoring and prevention are preferred over indiscriminate antibiotic use.