Nokea
A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: A
Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.
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A nurse is providing teaching to a client who is at 38 weeks of gestation and has a prescription to receive misoprostol intravaginally. Which of the following statement should the nurse make?
- A. "You will need to stay in a side-lying position for 30 minutes after each dose."
- B. "You will receive an IV infusion of oxytocin 1 hour after your last dose."
- C. " You will receive a magnesium supplement immediately following therapy."
- D. " You will need to have a full bladder before the therapy begins."
Correct Answer: A
Rationale: The correct statement the nurse should make to the client receiving misoprostol intravaginally is, "You will need to stay in a side-lying position for 30 minutes after each dose." This instruction is important because maintaining a side-lying position can help prevent leakage and promote proper absorption of the medication. It enhances the effectiveness of the medication and reduces the risk of its expulsion before absorption, ultimately leading to a better response to the treatment. The other options are not relevant to the administration of misoprostol intravaginally and do not align with best practice for this specific therapy.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
What history would lead you to suspect an ectopic pregnancy in a client at 8 weeks' gestation presenting with abdominal pain and bleeding?
- A. Treated one year ago for PID
- B. Irregular cycle for 1 year
- C. Oral contraception for 3 years
- D. Urinary frequency for 1 week
Correct Answer: A
Rationale: A history of previous pelvic inflammatory disease (PID) treatment would lead to suspicion of an ectopic pregnancy in a client presenting with abdominal pain and bleeding at 8 weeks' gestation. PID can cause scarring and damage to the fallopian tubes, increasing the risk of an ectopic pregnancy where the fertilized egg implants outside of the uterus, usually in the fallopian tubes. Symptoms of an ectopic pregnancy can include abdominal pain, vaginal bleeding, and signs of shock, making it important to consider this possibility in a client with a history of PID.
A client at 12 weeks' gestation reports mild cramping and spotting. What is the nurse's priority intervention?
- A. Reassure the client that this is normal.
- B. Encourage the client to hydrate.
- C. Advise the client to avoid heavy lifting.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Spotting and cramping in early pregnancy could indicate a threatened miscarriage, requiring immediate evaluation.
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.