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What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?
- A. Inform and assure the mother that this is normal weight loss.
- B. Encourage the mother to increase the frequency of breastfeeding.
- C. After verifying the accuracy of weight, notify the healthcare provider.
- D. Monitor the stool and urine output of the neonate for the last 24 hours.
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.
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A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
- A. Pain level
- B. Blood pressure
- C. Infusion site
- D. Contraction pattern
Correct Answer: D
Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.
The client is 24 hours postpartum and is being discharged. The nurse explains that vaginal discharge will change from red to pink and then to white. If the client starts having red bleeding after the color changes, what should the nurse instruct the client to do?
- A. Reduce activity level and notify the healthcare provider.
- B. Go to bed and assume a knee-chest position.
- C. Massage the uterus and go to the emergency room.
- D. Do not worry as this is a normal occurrence.
Correct Answer: A
Rationale: If the client experiences red bleeding after the color changes, it may indicate possible hemorrhage or retained placental fragments, which require immediate attention. Instructing the client to reduce activity level and notify the healthcare provider is crucial for prompt evaluation and management of potential complications.
A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes. Which action should the nurse take?
- A. Obtain blood culture.
- B. Administer penicillin.
- C. Cover lesion with a dressing.
- D. Prepare her for cesarean section.
Correct Answer: D
Rationale: Active herpes lesions at the time of delivery increase the risk of neonatal transmission. The most appropriate action in this scenario is to prepare the client for a cesarean section. A cesarean section is often recommended to reduce the risk of neonatal transmission of herpes simplex virus during delivery, especially when active lesions are present. This intervention helps minimize direct contact between the newborn and the infected genital tract secretions, thereby decreasing the risk of transmission.
During a routine first-trimester prenatal exam, a pregnant client tells the nurse that she has noticed an increase in vaginal discharge that is white, thin, and watery. Which action should the nurse implement?
- A. Recommend explaining the normal physiological changes during pregnancy.
- B. Notify the healthcare provider of the complaint.
- C. Inform her that this is a normal physiological change.
- D. Prepare to provide education on vaginal health.
Correct Answer: C
Rationale: The increased vaginal discharge described by the pregnant client, which is white, thin, and watery, is a common physiological change during pregnancy. It is typically normal and attributed to hormonal fluctuations. The nurse should reassure the client that this type of discharge is expected during pregnancy and does not typically indicate an issue requiring medical intervention or treatment.
During a non-stress test (NST) at 41-weeks gestation, the LPN/LVN notes that the client is not experiencing contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are present. What action should the nurse take?
- A. Check the client for urinary bladder distention.
- B. Notify the healthcare provider of the nonreactive results.
- C. Have the mother stimulate the fetus to move.
- D. Ask the client if she has felt any fetal movement.
Correct Answer: D
Rationale: In this scenario, the nurse should ask the client if she has felt any fetal movement. This action is important as assessing for fetal movement can help determine if the absence of FHR accelerations is attributed to fetal sleep or decreased fetal activity. It is crucial to gather information directly from the client to aid in the assessment and decision-making process. This approach can provide valuable insights into the fetal well-being and guide further interventions if needed.