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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According to the ACC/AHA guidelines, what factors are considered to assess a person's 10-year risk of developing a first cardiovascular event?
- A. age, sex, race, blood pressure, and smoking status
- B. age, sex, race, total cholesterol, HDL cholesterol, systolic blood pressure, blood pressure–lowering medication use, diabetes status, and smoking status
- C. blood pressure, cholesterol levels, diabetes status, and weight
- D. age, sex, race, and weight
Correct Answer: B
Rationale:
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.
The nurse is teaching a client with a midline episiotomy about perineal care after vaginal birth. Which statement from the client indicates she
- B. I will use the perineal bottle without touching perineum each time going to the bathroom
- C. I will gently pat perineal dry rather than wipe
- D. I will only use the perineal bottle after bowel movements
Correct Answer: C
Rationale: This statement indicates a correct understanding of perineal care after a midline episiotomy. After vaginal birth, it is important to avoid wiping the perineal area to prevent irritation and infection. Instead, gently patting the area dry is recommended to promote healing and prevent discomfort. This approach helps to minimize trauma to the sensitive tissues of the perineum and reduces the risk of introducing bacteria from wiping.
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 nurse is caring for a client who is receiving prenatal care and is at her 24- week appointment. Which of the following laboratory tests should the nurse plans to conduct?
- A. Group B strep culture
- B. 1-hr glucose tolerance test
- C. Rubella titer
- D. Blood type and Rh
Correct Answer: D
Rationale: At the 24-week prenatal appointment, it is essential to conduct the blood type and Rh test for the pregnant client. Determining the mother's blood type (A, B, AB, O) and Rh factor (positive or negative) is crucial as it helps identify if the mother is Rh-negative and at risk for Rh incompatibility with her baby. This information is vital for appropriate management to prevent potential complications such as hemolytic disease of the newborn. Conducting the blood type and Rh test at this stage allows healthcare providers to take necessary precautions to protect both the mother and the fetus.