Nokea
1-day-old newborn, indented anterior fontanelle
The nurse notices while holding him upright that a 1-day-old newborn has a significantly indented anterior fontanelle. She immediately brings it to the attention of the physician. What does this finding most likely indicate?
- A. Increased intracranial pressure.
- B. Vernix caseosa.
- C. Dehydration.
- D. Cyanosis.
Correct Answer: C
Rationale: An indented anterior fontanelle most likely indicates dehydration, as fluid loss causes the fontanelle to sink.
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Woman in labor, vacuum extraction
A maternal indication for the use of vacuum extraction is
- A. Maternal exhaustion.
- B. Failure to progress past 0 station.
- C. A wide pelvic outlet.
- D. A history of rapid deliveries.
Correct Answer: A
Rationale: Maternal exhaustion indicates vacuum extraction to assist delivery when the mother cannot push effectively, reducing fatigue and distress.
Pregnant woman educated about placental hormones
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
- A. Human placental lactogen (hPL).
- B. Estrogen (estriol).
- C. Progesterone (progestin).
- D. Human chorionic gonadotropin (hCG).
Correct Answer: D
Rationale: Human chorionic gonadotropin (hCG) is produced by the fertilized egg and detected in pregnancy tests, indicating fertilization and implantation.
Client 2 hours postpartum, vaginal birth, saturated two perineal pads in 30 minutes
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
- A. Assist the client on a bedpan to urinate.
- B. Increase the client's fluid intake.
- C. Palpate the client's uterine fundus.
- D. Prepare to administer oxytocic medication.
Correct Answer: C
Rationale: Palpating the uterine fundus assesses for uterine atony, a common cause of postpartum hemorrhage indicated by excessive bleeding.
Woman receiving oxytocin (Pitocin) infusion
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
- A. A woman in early labor with contractions every 5 minutes lasting 40 seconds each.
- B. A woman in active labor with contractions every 30 minutes lasting 60 seconds each.
- C. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each.
- D. A woman in transition with contractions every 1.5 minutes lasting 95 seconds each.
Correct Answer: D
Rationale: Contractions every 1.5 minutes lasting 95 seconds in transition indicate hyperstimulation, risking fetal distress, so the infusion should be stopped.
Laboring woman
The most appropriate time for the nurse to encourage a laboring woman to push is during
- A. the interval between contractions.
- B. whenever she feels the need.
- C. second-stage of labor.
- D. first-stage of labor.
Correct Answer: C
Rationale: The second stage of labor, when the cervix is fully dilated, is the appropriate time to push, as contractions are strong and effective for delivery.