Nokea
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent.
- B. Active.
- C. Early.
- D. Descent.
Correct Answer: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates fetal descent and impending birth. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage of labor. The passive descent phase occurs earlier when the cervix is not fully dilated. The early phase is part of the first stage of labor. Active labor typically begins when the cervix is around 6 cm dilated. Therefore, D is the correct choice as it aligns with the client's symptoms and stage of labor progression.
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A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a common behavioral indicator of pain in newborns. It is a subtle sign of distress and discomfort. Other choices such as decreased heart rate (A), pinpoint pupils (C), and slowed respirations (D) are not reliable indicators of pain in newborns. Decreased heart rate can indicate relaxation, pinpoint pupils are more indicative of opioid use, and slowed respirations might be a sign of sleepiness or relaxation rather than pain.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention. Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face.
- B. A newborn who is 32 hr old and has not passed a meconium stool.
- C. A newborn who is 12 hr old and has pink-tinged urine.
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F).
Correct Answer: B
Rationale: The correct answer is B. Failure to pass meconium stool within the first 24-48 hours after birth can indicate a possible intestinal obstruction or other issues that need immediate attention. Reporting this finding to the provider is crucial for further evaluation and intervention.
Choices A, C, and D are normal findings in newborns and do not require immediate reporting. E, F, and G are not applicable in this context.
Which of the following findings should the nurse report to the provider? Select all that apply
- A. Abdominal assessment.
- B. Vaginal Discharge.
- C. Heart rate.
- D. Temperature.
- E. Dyspareunia.
- F. Condom usage.
Correct Answer: B, E
Rationale:
The nurse should report vaginal discharge (B) as it could indicate infection or other issues. Dyspareunia (E) should also be reported as it can indicate underlying problems. Abdominal assessment (A) may be part of routine care but doesn't necessarily require immediate reporting. Heart rate (C) and temperature (D) are vital signs that should be monitored but don't specifically indicate a need for immediate reporting. Condom usage (F) is important for sexual health discussions but does not require reporting to the provider.