Nokea
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply.
- A. Blood in the diaper.
- B. Grunting during expiration.
- C. Deep red coloring on one side of the body with pale pink on the other side.
- D. Lacy and mottled appearance over the entire chest and abdomen.
Correct Answer: B
Rationale: Grunting indicates respiratory distress, and harlequin coloring suggests vascular compromise.
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A postoperative cesarean client, who was diagnosed with severe preeclampsia in labor and delivery, is transferred to the postpartum unit. The nurse is reviewing the client's doctor's orders. Which of the following medications that were ordered by the doctor should the nurse question?
- A. Methergine (methylergonovine).
- B. Magnesium sulfate.
- C. Advil (ibuprofen).
- D. Morphine sulfate.
Correct Answer: B
Rationale: Magnesium sulfate is contraindicated post-delivery.
A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is"bleeding and saturating a pad about every 1/2 hour."Which of the following is an appropriate response by the nurse?
- A. That is normal. You are starting to menstruate again.
- B. You should stay on complete bed rest until the bleeding subsides.
- C. Pushing during a bowel movement may have loosened your stitches.
- D. The physician should see you. Please go to the emergency department.
Correct Answer: D
Rationale: Heavy bleeding postpartum requires immediate medical attention.
Which anticipatory guidance action by the nurse makes role transition to parenthood easier?
- A. Helps the new parents identify resources.
- B. Recommends employing babysitters frequently.
- C. Tells the parents about the realities of parenthoo
- D. Offers a home phone number and tells parents to call if they have a question.
Correct Answer: A
Rationale: The correct answer is A because helping new parents identify resources promotes a smoother role transition by providing support and guidance. This action empowers parents to access necessary services and assistance. Choice B is incorrect as frequent babysitting does not address the parents' transition needs. Choice C is incorrect because focusing on the negatives may increase anxiety. Choice D is incorrect as it lacks proactive support and guidance.
The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis?
- A. Blood loss of 2,000 mL.
- B. Blood pressure of 160/110.
- C. Jaundiced skin color.
- D. Shortened prothrombin time.
Correct Answer: A
Rationale: Placenta accreta causes significant blood loss.
In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
- A. The woman complains of numbness in the toes and heel of one foot.
- B. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed.
- C. One of the woman's calves is swollen, red, and warm to the touch.
- D. The veins in the ankle of one of the woman's legs are spider-like and purple.
Correct Answer: C
Rationale: Swelling, redness, and warmth are classic signs of DVT.