Nokea
Which newborn behavior is normal and does not require immediate concern?
- A. Frequent hiccups
- B. Persistent vomiting
- C. Lethargy for days
- D. High fever
Correct Answer: A
Rationale: Frequent hiccups are normal in newborns and typically resolve without intervention, unlike the other symptoms.
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Twenty-four hours after the birth of her first child, the 25-year-old single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should the nurse suggest?
- A. An intrauterine device (IUD)
- B. Depot-medroxyprogesterone acetate injections
- C. A female condom with nonoxynol-9
- D. A diaphragm
Correct Answer: C
Rationale: IUDs offer no protection against STIs. They are recommended for women who are in a stable, mutually monogamous relationship. Depot-medroxyprogesterone acetate (Depo-Provera) is a long-acting progestin that is highly effective for birth control. A single injection will provide contraception for 3 months but does not offer protection against STIs. A female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter. A diaphragm offers no protection against STIs.
Which response by the nurse is correct concerning the legal threshold of viability?
- A. It is usually estimated to be 36 to 40 weeks.
- B. It is usually estimated to be 30 to 35 weeks.
- C. It is usually estimated to be 20 to 24 weeks.
- D. It is usually estimated to be 10 to 15 weeks.
Correct Answer: C
Rationale: The legal threshold of viability is typically 20-24 weeks, when a fetus may survive outside the womb with medical support.
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? Select all that apply.
- A. Oral temperature of 102.2°F (39°C)
- B. Telangiectasis on the neck and chest
- C. Mild abdominal tenderness with palpation
- D. Lochial discharge that is foul smelling
- E. White blood cell count of 16,500 cells/mm3
Correct Answer: A,D
Rationale: A temperature of 100.4°F (38°C) or higher after 24 hours postpartum is associated with a puerperal infection. Telangiectasis is red, slightly raised vascular “spiders” that may appear during pregnancy over the neck, thorax, face, or arms and remain or fade during the postpartum period. It is not indicative of an infection. Slight abdominal tenderness with palpation is a normal postpartum finding. Malodorous lochia is a common sign of a puerperal infection. A WBC count of 16,500 is normal for the postpartum client; labor produces a mild pro-inflammatory state.
Which statement made by a participant indicates the need for additional teaching regarding management of urinary frequency?
- A. Limiting fluid intake will help control this problem.
- B. I should report a burning sensation during urination.
- C. Urinating before going to bed may help control this problem.
- D. Avoiding caffeinated beverages may help control the problem.
Correct Answer: A
Rationale: Limiting fluid intake is not recommended, as hydration is essential; the other statements reflect appropriate management strategies.