Nokea
The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select one that doesn't apply
- A. Abortion at 10 weeks' gestation.
- B. Amniocentesis at 16 weeks' gestation.
- C. Fetal demise at 24 weeks' gestation.
- D. Birth of Rh-negative twins at 35 weeks' gestation.
Correct Answer: D
Rationale: RhoGAM is given in cases where there is potential exposure to Rh-positive blood.
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A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take?Select one that doesn't apply
- A. Swaddle the baby in a baby blanket.
- B. Discuss funeral options for the baby.
- C. Encourage the couple to try to get pregnant again in the near future.
- D. Ask the couple whether they would like to hold the baby.
Correct Answer: C
Rationale: Holding the baby and discussing funeral options support grieving.
To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body?
- A. Feet.
- B. Hands.
- C. Back.
- D. Mouth.
Correct Answer: D
Rationale: Epstein's pearls are small white nodules found on the gums or palate.
A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved?
- A. Moderate lochia flow.
- B. Decreased pain level.
- C. Stable blood pressure.
- D. Fundus above the umbilicus.
Correct Answer: A
Rationale: Improved lochia flow indicates resolution of atony.
The nurse is assessing a newborn on admission to the newborn nursery. Which of the following findings should the nurse report to the neonatologist?
- A. Intracostal retractions.
- B. Caput succedaneum.
- C. Epstein's pearls.
- D. Harlequin sign.
Correct Answer: A
Rationale: Intracostal retractions indicate respiratory distress and require immediate attention.
A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time?
- A. Monitor your blood glucose five times a day until your 6-week checkup.
- B. I will teach you how to inject insulin before you are discharged.
- C. Daily exercise will help to prevent you from becoming diabetic in the future.
- D. Your baby should be assessed every 6 months for signs of juvenile diabetes.
Correct Answer: A
Rationale: Gestational diabetes often resolves after delivery, but monitoring is still important.