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The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Shallow and irregular respirations.
- B. Flaring of the nares.
- C. Abdominal breathing with synchronous chest movement.
- D. Respiratory rate of 50 breaths per minute.
Correct Answer: B
Rationale: Nasal flaring indicates increased breathing effort, a sign of respiratory distress in newborns, unlike normal respiratory patterns.
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A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation.
- A. She may be experiencing postpartum preeclampsia.
- B. She may have an infection that needs further evaluation.
- C. Her symptoms could indicate anemia due to blood loss.
- D. She may be experiencing normal postpartum fatigue.
Correct Answer: A
Rationale: Symptoms like headache, visual disturbances, and nausea suggest postpartum preeclampsia, unlike infection, anemia, or normal fatigue, which don't typically include these signs.
When is the best time to administer a rubella vaccine to a client?
- A. After the client reaches 20-weeks gestation.
- B. Immediately, at 6-weeks gestation, to protect this fetus.
- C. Early postpartum, within 72 hours after delivery.
- D. After the client stops breastfeeding.
Correct Answer: C
Rationale: Administering the rubella vaccine postpartum within 72 hours ensures maternal immunity for future pregnancies without fetal risk, as it's a live vaccine contraindicated in pregnancy.
The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)
- A. Explaining procedures.
- B. Treating nausea.
- C. Ensuring side rails are padded.
- D. Assisting with breast pumping.
- E. Evaluating blood pressure frequently.
- F. Evaluating for headache.
- G. Assessing deep tendon reflexes.
Correct Answer: C,E,G,H
Rationale: Padded side rails, frequent blood pressure checks, reflex assessment, and minimizing visitors stabilize the client by preventing injury, monitoring hypertension, and reducing seizure triggers.
Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?
- A. Low back pain with pelvic cramping.
- B. Headache and blurred vision.
- C. Increased fetal movement.
- D. Epigastric pain.
Correct Answer: A
Rationale: Low back pain and pelvic cramping post-amniocentesis may signal complications like premature labor or infection, requiring immediate evaluation.
History and Physical:
Nurses' Notes:
Vital Signs:
Laboratory Results:
The client is a 28-year-old primiparous female who was induced at 41 weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock.
A nurse is caring for a primiparous client in the postpartum unit. The client was induced at 41 weeks gestation with misoprostol and oxytocin and gave birth vaginally 4 days ago. She was discharged home on day two with her newborn and has been breastfeeding around the clock. She called her healthcare provider this morning with fatigue, new-onset headache, nausea, dizziness, weakness, and seeing "flashing lights."
The nurse reviews the client's history, physical, and flow sheet to determine the cause of the client's symptoms. Highlight the information from the history, physical, and flow sheet that require further evaluation. Select all that apply.
- A. Hemoglobin 10.4 g/dL (6.45 mmol/L)
- B. Platelets 150,000/mm³ (150 x 10â¹/L)
- C. New-onset headache
- D. Vomiting small amount of yellow fluid
- E. Right upper quadrant pain
- F. Seeing flashing lights
- G. Elevated blood pressure
Correct Answer: C,D,E,F,G
Rationale: Headache, vomiting, right upper quadrant pain, flashing lights, and elevated blood pressure suggest postpartum preeclampsia or HELLP syndrome, requiring urgent evaluation.