Nokea
The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?
- A. Improve insufficient dietary intake.
- B. Stimulate the immune system.
- C. Prevent hemorrhagic disorders.
- D. Help an immature liver.
Correct Answer: C
Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.
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A woman in her third trimester of pregnancy has been in active labor for the past 8 hours and has dilated 3 cm. The nurse's assessment findings and electronic fetal monitoring (EFM) are consistent with hypotonic dystocia, and the healthcare provider (HCP) prescribes an oxytocin drip. Which data is most important for the nurse to monitor?
- A. Preparation for emergency cesarean birth.
- B. Intensity, interval, and length of contractions.
- C. Checking the perineum for bulging.
- D. Client's hourly blood pressure.
Correct Answer: B
Rationale: Monitoring contraction patterns ensures oxytocin efficacy and prevents hyperstimulation in hypotonic dystocia, critical for labor progression.
A client in the third trimester of pregnancy is troubled by frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated and she has an increased costal angle. Which intervention should the nurse implement?
- A. Ask a nurse with more experience to validate the costal angle finding.
- B. Examine the client for signs of tissue anoxia, such as pallor.
- C. Ask the healthcare provider to evaluate the client's respiratory status.
- D. Record the respiratory finding in the client's record as normal.
Correct Answer: D
Rationale: These respiratory changes are normal pregnancy adaptations due to uterine expansion, requiring only documentation as normal findings.
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.
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Give zidovudine 6 to 12 hours after birth.
- C. Administer antibiotics for 7 to 10 days.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: B
Rationale: Zidovudine within 6-12 hours reduces HIV transmission risk in newborns of HIV-positive mothers, unlike breastfeeding, which is contraindicated, or antibiotics and delayed bathing, which are irrelevant.
Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?
- A. Heart rate of 56 beats/minute.
- B. Saturating two perineal pads per hour.
- C. Soft, spongy fundus.
- D. Unilateral lower leg pain.
Correct Answer: A
Rationale: Bradycardia (56 beats/minute) is normal postpartum due to increased stroke volume, unlike excessive bleeding, uterine atony, or DVT signs.