Nokea
Which conditions create a risk for uterine atony in the immediate postpartum period?
- A. Breastfeeding and delivery of an infant with chromosome defects
- B. Postterm birth and an amniotomy during labor
- C. Gestational diabetes and pregnancy-induced hypertension
- D. Multiparity and multiple gestation
Correct Answer: D
Rationale: Step-by-step rationale for why choice D is correct:
1. Multiparity: Women who have had multiple pregnancies are at higher risk for uterine atony due to uterine muscle fatigue.
2. Multiple gestation: The presence of more than one fetus puts increased demands on the uterus, increasing the risk of uterine atony.
Summary of why other choices are incorrect:
- A: Breastfeeding and chromosome defects are not directly linked to uterine atony.
- B: Postterm birth and amniotomy do not inherently increase the risk of uterine atony.
- C: Gestational diabetes and pregnancy-induced hypertension are not specific risk factors for uterine atony.
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A nurse is performing a physical assessment of a newborn. Which of the following clinical findings should the nurse expect? (Select all that apply).
- A. Heart Rate 154/min
- B. Axillary temperature 96.8 F
- C. Respiratory rate 58/min
- D. Length 43 cm (16.9in)
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D.
1. Heart rate of 154/min is expected in a newborn, indicating normal cardiac function.
2. Axillary temperature of 96.8 F is within the normal range for a newborn.
3. Respiratory rate of 58/min is expected due to the newborn's immature respiratory system.
4. Length of 43 cm (16.9 in) falls within the normal range for a newborn's size.
Incorrect choices are not applicable due to lack of details, but in general, incorrect options would have included values outside the normal range for a newborn's physical assessment.
A client delivered vaginally six hours ago. Which assessment finding can be interpreted as normal?
- A. Temperature 100.0 degrees F
- B. Blood pressure 140/90
- C. Respirations 10
- D. Pulse 90
Correct Answer: A
Rationale: The correct answer is A: Temperature 100.0 degrees F. This finding can be interpreted as normal because a slight increase in body temperature after childbirth is expected due to the physiological changes during labor. A temperature of 100.0 degrees F is within the normal range for postpartum women.
Rationale for why the other choices are incorrect:
B: Blood pressure 140/90 - This blood pressure reading is slightly elevated and may indicate hypertension, which would not be considered normal postpartum.
C: Respirations 10 - A respiratory rate of 10 is abnormally low and could indicate respiratory distress rather than normal postpartum recovery.
D: Pulse 90 - A pulse rate of 90 may be within normal limits, but it is not as indicative of normal postpartum recovery as a slightly elevated temperature would be.
Which site is preferred for giving an IM injection to a newborn?
- A. Ventrogluteal
- B. Vastus lateralis
- C. Rectus femoris
- D. Dorsogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. The vastus lateralis muscle is preferred for IM injections in newborns due to its large muscle mass, minimal risk of injury to major blood vessels and nerves, and easy accessibility. It is also recommended by healthcare guidelines for infants. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of damaging nerves and blood vessels. The rectus femoris muscle is not typically used for IM injections in newborns as it is less accessible and has a higher risk of injury.
The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?
- A. To determine whether the client's cervix has dilated
- B. To assess the frequency and intensity of the contractions
- C. To assess whether membranes have been ruptured
- D. To determine the presentation and position of the fetus
Correct Answer: D
Rationale: The correct answer is D: To determine the presentation and position of the fetus. Leopold's maneuvers involve a series of palpations to assess the fetal lie, presentation, position, and engagement. By performing these maneuvers, the nurse can determine the position of the fetus in relation to the mother's pelvis and whether the baby is in a vertex or breech presentation. This information is crucial in planning for a safe delivery and identifying any potential complications.
Other choices are incorrect because:
A: Leopold's maneuvers do not directly assess cervical dilation.
B: Contractions are typically monitored separately using a tocodynamometer.
C: Checking for ruptured membranes is done through a separate assessment.
In summary, Leopold's maneuvers primarily focus on assessing the presentation and position of the fetus to guide the delivery process effectively.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.