Nokea
Which assessment finding indicates a complication in a client attempting a VBAC?
- A. Complaint of pain between the scapula (could be uterine
- C. Contraction every 3 minutes lasting 70 seconds
- D. Pain level 6 at acme of
Correct Answer: C
Rationale: A client attempting a Vaginal Birth After Cesarean (VBAC) is at higher risk for uterine rupture. A concerning assessment finding in this scenario would be the occurrence of contractions every 3 minutes that are lasting 70 seconds. This pattern of contractions could potentially indicate uterine hyperstimulation, which increases the risk of uterine rupture. It is essential to closely monitor these contractions and address any signs of distress or complications promptly to ensure the safety of both the mother and the baby.
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What action is of highest priority for a nurse seeing a woman with multiple bruises accompanied by her partner?
- A. Take the woman's vital signs.
- B. Interview the woman in private.
- C. Assess for additional bruising.
- D. Document the location of the bruises.
Correct Answer: B
Rationale: Private interviews uncover hidden abuse.
After her baby's birth a patient wishes to begin breastfeeding. The nurse assists the client by:
- A. Positioning the infant to grasp the nipple to express milk.
- B. Giving the infant a bottle first to evaluate the baby's ability to suck
- C. Leaving them alone and allowing the infant to nurse as long as desired
- D. Touching the infant's cheek adjacent to the nipple to elicit the rooting reflex
Correct Answer: D
Rationale: The rooting reflex helps initiate breastfeeding.
The nurse is teaching a prenatal class about fetal development. When does the heart begin to beat?
- A. At 4 weeks' gestation.
- B. At 8 weeks' gestation.
- C. At 12 weeks' gestation.
- D. At 16 weeks' gestation.
Correct Answer: A
Rationale: The fetal heart begins beating as early as 4 weeks' gestation, signaling early circulatory development.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
For which condition should the nurse immediately
- A. Applying her peri-pad from back to front with notify the health care team?
- B. Periodic breathing in the newborn lasting
- C. Using the peri-bottle to rinse her perineum after approximately 3 to 5 seconds
- D. Blood sugar recording of 60 mg/dL in an infant born 6 hours ago
Correct Answer: D
Rationale: A blood sugar recording of 60 mg/dL in an infant born 6 hours ago requires immediate notification of the health care team. This low blood sugar level, also known as hypoglycemia, is a critical concern in newborns as it can lead to serious complications if not promptly addressed. Infants are particularly vulnerable to hypoglycemia due to their limited glycogen stores and high metabolic demands, which can result in inadequate glucose production. Immediate intervention and close monitoring by the healthcare team are essential to prevent potential long-term neurological consequences associated with hypoglycemia in newborns.