Nokea
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance ... that crosses the suture line. The nurse should identify the swellings as which of the following....?
- A. Nevus flammeus
- B. Caput uccedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: C
Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.
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A patient had unprotected sex yesterday. She is interested in emergency contraception. The nurse knows that the patient has how long to take the medication for it to be effective?
- A. 24 hr
- B. 48 hr
- C. 3 days
- D. 5 days
Correct Answer: C
Rationale: Emergency contraception is most effective if taken within 3 days after unprotected sex. The sooner it is taken, the more effective it is. Choice A and B are incorrect because they are too short a time window for emergency contraception to be effective. Choice D is also incorrect because most emergency contraceptive pills are not effective after 5 days.
A woman admitted to the labor and delivery unit in bruising over the shoulder area and an abrasion on early labor gives the following obstetric history. She the scalp. What are these markings most likely the gave birth to her daughter at 38 weeks and her twin result of?
- A. Suspected drug use during pregnancy
- B. Abuse by a caregiver
- C. Soft tissue injury during delivery
- D. Blue/gray macule (Mongolian spot)
Correct Answer: B
Rationale: The bruising over the shoulder area and the abrasion on the scalp of a woman admitted to the labor and delivery unit during early labor are most likely the result of abuse by a caregiver. These types of injuries can be indicative of physical abuse, especially in vulnerable populations such as pregnant women. It is important for healthcare providers to be alert for signs of abuse and to report any suspicions or evidence to ensure the safety of the mother and the baby. In cases like this, a thorough assessment and appropriate intervention are necessary to protect the well-being of the mother and the unborn child.
The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: C
Rationale: Neonatal weight loss in the first 3 days of life is most often the result of inadequate breast or formula feeding. During the initial days of life, it is normal for newborn babies to experience some weight loss. This weight loss is generally due to factors such as insufficient intake of breast milk or formula. It takes a few days for a mother's mature breast milk to come in, and during this time, a newborn may not receive enough colostrum, which can lead to initial weight loss. Similarly, if a baby is not getting enough formula or is having feeding difficulties, this can also result in weight loss. Allergy to formula, a hypoglycemic response, or excretion of fluid via lungs, urinary bladder, and bowels are less likely explanations for neonatal weight loss in the first 3 days of life compared to inadequate feeding.
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
A patient has just had a Mirena IUD inserted. What is the most important information for the nurse to include in the post-procedure instructions?
- A. You may experience severe cramping and should rest for several days.
- B. You should check the strings of the IUD regularly to ensure it is in place.
- C. You should avoid sexual activity for the first month after the insertion.
- D. The IUD will make your periods longer and heavier for the first 6 months.
Correct Answer: B
Rationale: The patient should be instructed to check the strings of the IUD regularly to ensure it remains in place. Choice A is not accurate because while cramping is common, rest is not necessarily required for several days. Choice C is not required; there is no need to avoid sexual activity unless there is an infection or other complication. Choice D is incorrect as Mirena typically reduces bleeding or makes periods lighter.