Nokea
The nurse is to assess a newborn for incurving of the trunk. Which illustration indicates the position in which the nurse should place the newborn?
Correct Answer: B
Rationale: To assess for incurving of the trunk, the newborn should be placed in a side-lying position to observe spinal curvature.
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A post-term neonate diagnosed with persistent pulmonary hypertension is prescribed intravenous tolazoline (Priscoline). While administering this drug, the nurse should monitor the neonate for?
- A. Feeding behaviors.
- B. Temperature.
- C. Skin color.
- D. Blood pressure.
Correct Answer: D
Rationale: Tolazoline is a vasodilator, and monitoring blood pressure is critical due to the risk of hypotension.
The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should:
- A. Ask the client if this is acceptable to her.
- B. Have the client and her husband both sign the consent form.
- C. Ask the client to sign the consent form.
- D. Ask the doctor to witness the consent form.
Correct Answer: C
Rationale: The client must provide informed consent unless incapacitated. The nurse should ask the client to sign, ensuring she understands despite her distress. The husband cannot sign unless legally authorized, and dual signatures or physician witnessing are unnecessary.
While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity?" Which of the following responses by the nurse would be most appropriate?
- A. Ignore the client's question and continue with morning care.
- B. Tell the client "I'm not sure how the other woman is doing today."
- C. Tell the client "I need to ask the woman's permission before discussing her well-being."
- D. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."
Correct Answer: D
Rationale: Nurses must maintain patient confidentiality, making it inappropriate to discuss another client's status.
Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.
A multigravid client at 34 weeks' gestation is being treated with indomethacin(Indocin) to halt preterm labor. If the client delivers a preterm infant, the nurse should notify the nursery personnel about this therapy because of the possibility for which of the following?
- A. Pulmonary hypertension.
- B. Respiratory distress syndrome(RDS).
- C. Hyperbilirubinemia.
- D. Cardiomyopathy.
Correct Answer: C
Rationale: Indomethacin can increase the risk of hyperbilirubinemia in preterm infants.