Nokea
Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
- A. Heart rate.
- B. Blood pressure.
- C. Temperature.
- D. Facial expression.
Correct Answer: A
Rationale: Heart rate and facial expression are key indicators of neonatal pain.
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A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
- A. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs.
- B. Gently adduct and abduct the baby's thighs.
- C. Palpate the trochanter during hip rotation.
- D. Place the baby in a fetal position.
Correct Answer: D
Rationale: These maneuvers help detect instability or asymmetry in the hips indicative of DDH.
To check for the presence of Epstein's pearls, the nurse should assess which part of the neonate's body?
- A. Feet.
- B. Hands.
- C. Back.
- D. Mouth.
Correct Answer: D
Rationale: Epstein's pearls are small white nodules found on the gums or palate.
A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client?
- A. The woman should never be left alone with her infant.
- B. Symptoms rarely last more than one week.
- C. Clinical response to medications is usually poor.
- D. The woman must have her vitals assessed every two days.
Correct Answer: A
Rationale: Safety is paramount with psychosis.
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: The correct answer is B: full bladder. A full bladder can cause the fundus to be boggy, elevated, and deviated to one side due to impeding the uterus from contracting properly. This can lead to postpartum hemorrhage. Uterine rupture (A) would present with severe abdominal pain and signs of shock. Perineal laceration (C) would not cause these fundus changes. Hematoma (D) would present with localized swelling and pain, not fundal changes.
The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select one that doesn't apply
- A. Abortion at 10 weeks' gestation.
- B. Amniocentesis at 16 weeks' gestation.
- C. Fetal demise at 24 weeks' gestation.
- D. Birth of Rh-negative twins at 35 weeks' gestation.
Correct Answer: D
Rationale: RhoGAM is given in cases where there is potential exposure to Rh-positive blood.