Nokea
The nurse is preparing a client for a postpartum tubal ligation. What is the priority preoperative nursing action?
- A. Insert an indwelling catheter.
- B. Verify signed informed consent.
- C. Administer prescribed antibiotics.
- D. Check for maternal vital signs.
Correct Answer: B
Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.
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A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
- A. Bulging Fontanels
- B. Nasal Flaring
- C. Length from head to heel of 40 cm (15.7 in)
- D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Correct Answer: D
Rationale: When a nurse is assessing a newborn upon admission to the nursery, it is expected that the chest circumference will be smaller than the head circumference. This is a normal finding in a newborn, where the head circumference is slightly larger than the chest circumference due to the proportionate sizes of the newborn's head and chest. This difference helps accommodate the vital organs within the chest cavity while allowing for the growth and development of the brain. Therefore, a chest circumference that is 2 cm smaller than the head circumference is a typical and expected finding in a newborn assessment.
A delivering patient presses the call light and reports that her water just broke the nurse first action should be:
- A. Check the fetal heart tone
- B. Call physician
- C. Change bed linen
- D. Encourage mother to go for a walk
Correct Answer: A
Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.
What is the primary nursing action for a newborn experiencing signs of hypoglycemia?
- A. Administer glucose water via a bottle
- B. Feed the newborn breastmilk or formula
- C. Monitor glucose levels and reassess in 30 minutes
- D. Start an IV glucose drip
Correct Answer: B
Rationale: Feeding with breastmilk or formula is the most effective intervention for neonatal hypoglycemia.
The nurse is teaching a client about postpartum warning signs. Which symptom should be reported immediately?
- A. Increased lochia on standing.
- B. Breast tenderness and fullness.
- C. Severe headache and blurred vision.
- D. Mild swelling in the feet.
Correct Answer: C
Rationale: Severe headache and blurred vision may indicate postpartum complications such as preeclampsia.