Nokea
Two hours ago, a neonate at 38 weeks' gestation and weighing 3,175 g (7 lb) was born to a primiparous client who tested positive for beta-hemolytic Streptococcus. Which of the following would alert the nurse to notify the pediatrician?
- A. Alkalosis.
- B. Increased muscle tone.
- C. Temperature instability.
- D. Positive Babinski's reflex.
Correct Answer: C
Rationale: Temperature instability can indicate early sepsis, especially in a neonate at risk due to maternal beta-hemolytic Streptococcus.
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A multigravid client is admitted to the labor area from the emergency room. At the time of admission, the fetal head is crowning, and the client yells, 'The baby's coming!' To help the client remain calm and cooperative during the imminent delivery, which of the following responses by the nurse is most appropriate?
- A. You're right, the baby is coming, so just relax.'
- B. Please don't push because you'll tear your cervix.'
- C. Your doctor will be here as soon as possible.'
- D. I'll explain what's happening to guide you as we go along.'
Correct Answer: D
Rationale: Explaining the process and guiding the client during a precipitous delivery promotes cooperation and reduces anxiety. Telling her to relax is unhelpful, warning against pushing is inaccurate (cervix is fully dilated), and focusing on the doctor's arrival is irrelevant.
The nurse managing the admission nursery is beginning the shift. There are 2 infants under the care of a primary staff nurse and are remaining in the nursery while their mothers sleep. One newborn is waiting to be transferred to the special care nursery (SCN) with a diagnosis of possible sepsis. The SCN cannot accept a transfer for 30 minutes. The nurse has been notified that another infant has been born and is breathing at a rate of 80 bpm and needs to be admitted to the nursery. There are also two infants who are waiting for social services to determine discharge plans. There can be no other additions to the nursery until at least one newborn leaves the area. How should the nurse manage this situation?
- A. Ask the nurses in SCN if they can take the newborn with possible sepsis now.
- B. Ask the primary staff nurses to take their babies back to the sleeping mothers' rooms.
- C. Call social services to determine if either of the babies who are waiting to be discharged are ready to leave.
- D. Ask the nurse with the infant who is breathing at 80 bpm to wait ½ hour.
Correct Answer: C
Rationale: Calling social services to expedite discharge of one of the waiting infants allows space for the new admission with a high respiratory rate, which requires urgent assessment.
A client asks about the effectiveness of male condoms. Which of the following responses by the nurse is accurate?
- A. They are 100% effective in preventing pregnancy.
- B. They are highly effective when used correctly.
- C. They require a prescription.
- D. They are less effective than the withdrawal method.
Correct Answer: B
Rationale: Male condoms are highly effective when used correctly, with a low failure rate. They are not 100% effective, do not require a prescription, and are more effective than the withdrawal method.
Which of the following anticoagulants would the nurse expect to administer when caring for a primigravid client at 12 weeks' gestation who has class II cardiac disease due to mitral valve stenosis?
- A. Heparin.
- B. Warfarin(Coumadin).
- C. Enoxaparin(Lovenox).
- D. Ardeparin(Normiflo).
Correct Answer: A
Rationale: Heparin is safe during pregnancy and does not cross the placenta.
A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confirm this diagnosis? Select all that apply.
- A. Hypotension.
- B. Gush of blood from the vagina.
- C. Intense, severe, tearing type of abdominal pain.
- D. Uterus is hard and in a constant state of contraction.
- E. Inability to palpate the uterus.
- F. Diaphoresis.
Correct Answer: A,E
Rationale: Uterine inversion is characterized by the uterus turning inside out, often leading to hypotension (due to shock) and inability to palpate the fundus abdominally. A gush of blood may occur but is not specific, severe pain is less common, the uterus is not typically hard, and diaphoresis is a secondary symptom.