Nokea
When performing an initial assessment of a post-term male neonate weighing 4,000 g (9 lb) who was admitted to the observation nursery after a vaginal delivery with low forceps, the nurse detects Ortolani's sign. Which of the following actions should the nurse do next?
- A. Determine the length of the mother's labor.
- B. Notify the pediatrician immediately.
- C. Keep the neonate under the radiant warmer for 2 hours.
- D. Obtain a blood sample to check for hypoglycemia.
Correct Answer: B
Rationale: Ortolani's sign indicates possible developmental dysplasia of the hip, and immediate notification of the pediatrician is necessary.
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A client is considering the cervical cap. Which of the following statements by the nurse is accurate?
- A. The cervical cap can be left in place for up to 72 hours.
- B. The cervical cap does not require spermicide.
- C. The cervical cap requires a prescription and fitting.
- D. The cervical cap is highly effective for women who have given birth.
Correct Answer: C
Rationale: The cervical cap requires a prescription and fitting by a healthcare provider for proper use. It can be left in place for up to 48 hours, requires spermicide, and is less effective for women who have given birth.
A 24-year-old client is discussing contraception options with the nurse and expresses interest in an intrauterine device (IUD). Which of the following statements by the client indicates a need for further teaching?
- A. I understand the IUD can remain in place for several years.
- B. The IUD will prevent ovulation each month.
- C. I may experience heavier menstrual periods with the copper IUD.
- D. The IUD does not protect against sexually transmitted infections.
Correct Answer: B
Rationale: The IUD does not primarily prevent ovulation; it works by affecting sperm movement and preventing fertilization (copper IUD) or thinning the uterine lining (hormonal IUD). The other statements are correct, indicating a need for further teaching about its mechanism.
While caring for the neonate of a human immunodeficiency virus-positive mother, the nurse prepares to administer an ordered hepatitis B intramuscular injection at 4 hours after birth. Which of the following actions should the nurse do first?
- A. Bathe the neonate with an antibacterial soap.
- B. Place the neonate under a radiant warmer.
- C. Wash the injection site with povidone-iodine (Betadine) solution.
- D. Apply clean gloves before administering the medication.
Correct Answer: D
Rationale: Applying clean gloves ensures infection control and safety during the administration of the injection.
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
- A. Taking in.
- B. Taking on.
- C. Taking hold.
- D. Letting go.
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.
A 25-year-old primiparous client who delivered a viable neonate 2 hours ago has decided to breast-feed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?
- A. Keeping plastic liners in the brassiere to keep the nipple drier.
- B. Placing as much of the areola as possible into the baby's mouth.
- C. Smoothly pulling the nipple out of the mouth after 10 minutes.
- D. Removing any remaining milk left on the nipple with a soft washcloth.
Correct Answer: B
Rationale: Proper latch with the areola in the baby's mouth prevents nipple soreness by reducing trauma.