Nokea
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.
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A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)
- A. Administer nitric oxide inhalation therapy to the newborn
- B. Insert an orogastric decompression tube with low wall suction.
- C. Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
- D. Measure the abdominal circumference at the level of the newborn's umbilicus every 2 hr.
Correct Answer: D
Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.
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.
Why is it important to consider special considerations, such as age, cultural background, or specific health conditions, during a health history for a well-person exam?
- A. to tailor the examination and screening tests to the individual’s health needs
- B. to assess the risk of occupational and environmental exposures
- C. to determine the individual's immunization history
- D. to identify potential safety considerations, such as intimate partner violence or mental abuse
Correct Answer: A
Rationale:
is a vitamin supplement prescribed for clients who have hyperemesis gravidarum.
- A. INCORRECT: Ferrous sulfate is a medication used in the treatment of iron deficiency anemia.
- B. CORRECT: Calcium gluconate is the antidote for magnesium sulfate. the baby is inside. What is the nurse9s best response?
- C. "Your baby's umbilical cord is surrounded by connective tissue called Wharton jelly, which prevents compression of the blood vessels and ensures continued nourishment of your baby."
Correct Answer: B
Rationale: Calcium gluconate is indeed the antidote for magnesium sulfate toxicity. In cases where a pregnant client is receiving magnesium sulfate for conditions like preeclampsia, it is important to have calcium gluconate readily available in case of magnesium toxicity. This is a crucial intervention to prevent any adverse effects on both the mother and the baby. So, the nurse should ensure that calcium gluconate is available and be prepared to administer it if needed.
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.