Nokea
The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?
- A. Offer a pacifier dipped in glucose water.
- B. Give a PRN dose of liquid acetaminophen.
- C. Place petrolatum gauze dressings on the site.
- D. Wrap the infant in warm receiving blankets.
Correct Answer: C
Rationale: Petrolatum gauze prevents wound adherence to diapers, reducing irritation and infection risk, prioritizing post-circumcision care.
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One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell (WBC) count is 15,000/mm³ (15 x 10â¹/L). Which action should the nurse take first?
- A. Check the differential, since the WBC is normal for this client.
- B. Assess the client's perineal area for signs of a perineal hematoma.
- C. Assess the client's temperature, heart rate, and respirations every 4 hours.
- D. Notify the healthcare provider (HCP), since this finding is indicative of infection.
Correct Answer: A
Rationale: A WBC count of 15,000/mm³ is normal postpartum due to physiological stress; checking the differential confirms this, avoiding unnecessary interventions.
A primiparous client was induced at 41-weeks gestation with misoprostol and oxytocin. She gave birth vaginally 4 days ago, and her prenatal course and delivery were uncomplicated. She was discharged home on day two with her newborn and has been breastfeeding around the clock. Discharge prescription included ferrous sulfate 325 mg PO twice daily. Client called her healthcare provider (HCP) this morning with fatigue, new onset of headache that was not relieved with ibuprofen, nausea, dizziness, weakness, and seeing “flashing lights.â€. Client was instructed to come to the hospital for evaluation.
- A. She may be experiencing postpartum preeclampsia.
- B. She may have an infection that needs further evaluation.
- C. Her symptoms could indicate anemia due to blood loss.
- D. She may be experiencing normal postpartum fatigue.
Correct Answer: A
Rationale: Symptoms like headache, visual disturbances, and nausea suggest postpartum preeclampsia, unlike infection, anemia, or normal fatigue, which don't typically include these signs.
At 0600, while admitting a woman for a scheduled repeat cesarean section (C-section), the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?
- A. Start prescribed IV with lactated Ringer's.
- B. Inform the anesthesia care provider.
- C. Ensure preoperative lab results are available.
- D. Contact the client's obstetrician.
Correct Answer: B
Rationale: Caffeine intake may alter anesthesia effects, and the anesthesiologist needs to be informed first to manage potential complications like increased gastric acidity and delayed gastric emptying.
During the admission of a newborn, the nurse identifies a localized swelling that does not cross the suture line on the posterior area of the parietal bone. Which action should the nurse implement?
- A. Apply direct pressure to the caput succedaneum.
- B. Submit a request for a STAT Computerized Tomography (CT) scan of the head.
- C. Notify the pediatrician of the cephalhematoma.
- D. Assess neurological vital signs every 4 hours.
Correct Answer: C
Rationale: A cephalhematoma, not crossing suture lines, requires pediatrician notification to monitor for complications like jaundice, unlike caput succedaneum or unnecessary CT scans.
The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?
- A. Bolus of 2 ml/kg glucose 10% IV.
- B. Feed immediately.
- C. Echocardiogram.
- D. Monitor for respiratory distress.
- E. Apply dextrose gel inside the baby's cheek.
Correct Answer: E
Rationale: Applying dextrose gel is a rapid, non-invasive way to treat hypoglycemia, prioritizing immediate glucose stabilization in a jittery newborn.