Nokea
Which newborn reflex is assessed by stroking the cheek?
- A. Startle reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Sucking reflex
Correct Answer: B
Rationale: The rooting reflex is observed when stroking the cheek, helping the newborn find the breast for feeding.
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The nurse is teaching a client about signs of postpartum hemorrhage. What statement indicates understanding?
- A. Passing a few clots is normal.
- B. Soaking one pad in an hour is concerning.
- C. Heavy bleeding stops within 48 hours.
- D. I should ignore mild cramping.
Correct Answer: B
Rationale: Soaking a pad in an hour may indicate postpartum hemorrhage and should be reported immediately.
The physician has determined the need for forceps. The nurse should explain to the patient that the need for forceps is indicated because
- A. Premature placental separation (also used for prolapsed cord and nonreasoning fetal HR)
- B. Her support person is exhausted
- C. To shorten the first stage of labor
- D. To prevent fetal distress
Correct Answer: A
Rationale: Forceps delivery is indicated in situations where there is fetal distress due to premature placental separation or nonreassuring fetal heart rate. Forceps are used to facilitate a quicker delivery and reduce the risk to the baby during such emergency situations. Forces are also used in cases of fetal distress due to a prolapsed cord where a quick delivery is necessary to relieve pressure on the umbilical cord.
A nurse is caring for a client who is in the first stage of labor and is using pattern-paced breathing. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?
- A. Administer oxygen via nasal cannula.
- B. Assist the client to breathe into a paper bag.
- C. Have the client tuck her chin to her chest.
- D. Instruct the client to increase her respiratory rate to more than 42 breaths per min.
Correct Answer: A
Rationale: The client is exhibiting signs of hyperventilation, which can occur as a result of rapid breathing techniques such as pattern-paced breathing during labor. Administering oxygen via nasal cannula can help the client rebalance her oxygen and carbon dioxide levels, which will alleviate the lightheadedness and tingling sensations she is experiencing. Oxygen therapy is the appropriate intervention for respiratory alkalosis caused by hyperventilation. Assisting the client to breathe into a paper bag or instructing her to increase her respiratory rate would exacerbate the hyperventilation and should be avoided. Tucking her chin to her chest is not an appropriate intervention in this situation.
A client with chronic kidney disease has arterial blood gas values being reviewed by a nurse. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
- C. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- D. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
Correct Answer: A
Rationale: In chronic kidney disease, metabolic acidosis is common due to impaired kidney function leading to reduced bicarbonate excretion. The correct values indicating metabolic acidosis in this scenario are a low pH (acidosis), low bicarbonate (HCO3-) level, and low PaCO2 (compensation through respiratory alkalosis). Therefore, the expected values for a client with chronic kidney disease would be pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg, as depicted in choice A.
A 35-year-old patient comes to the clinic 2 days after a tubal ligation. She complains of abdominal pain and swelling and redness at the surgical incision. What does the nurse know is a common complication of this procedure?
- A. Ileus
- B. Liver enlargement
- C. Constipation
- D. Infection
Correct Answer: D
Rationale: Infection is a common complication after tubal ligation, indicated by redness and swelling at the surgical site. Choice A is incorrect as ileus is a bowel obstruction, not typically a complication of tubal ligation. Choice B, liver enlargement, is unrelated to tubal ligation. Choice C, constipation, may be a side effect but is not a primary concern after this procedure.