Nokea
Which of the following assessment findings requires Immediate follow-up? Select all that apply,
- A. Platelet count
- B. Vaginal bleeding
- C. HCT
- D. RBC Count
- E. Fetal heart rate
- F. hgb
- G. WBC Count
Correct Answer: B,C,E,F
Rationale: The correct answers are B, C, E, and F. Vaginal bleeding requires immediate follow-up to assess for potential complications. HCT, HGB, and WBC count are crucial for evaluating maternal health. Fetal heart rate is essential for monitoring fetal well-being. Platelet count and RBC count are important but not as urgent as the other findings.
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A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Increased warmth in the extremity: Indicates clot progression or inflammation.
- Tachycardia: Can signify a pulmonary embolism or worsening condition.
- Leukocytosis: Suggests infection or inflammatory response.
- Scant lochia rubra: Not directly related to deep vein thrombosis, more common postpartum.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. The leaking cerebrospinal fluid puts the newborn at risk for infection, so administering antibiotics helps prevent infection. Monitoring rectal temperature (B) is not directly related to preventing infection. Cleansing the site with povidone-iodine (C) may not be effective in preventing infection. Preparing for surgical closure after 72 hr (D) is important but addressing the risk of infection with antibiotics is the immediate priority.
A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: The correct answer is D: Notify the provider if the end of your baby’s penis appears dark red. This is important to monitor for signs of infection, such as redness, swelling, or discharge. Yellow exudate forming in 24 hours (C) is incorrect as it may indicate infection. The Plastibell is typically removed after a few days, not 4 hours (A). Ensuring a snug diaper (B) is irrelevant to the circumcision technique.
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by stimulating ovulation. Breast tenderness is a common side effect due to the hormonal changes it induces, as it can lead to increased estrogen levels. This is important for the nurse to include in teaching as it prepares the client for a potential adverse effect.
B: Tinnitus, C: Urinary frequency, D: Chills are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency is not a known side effect of clomiphene, and chills are not a typical reaction to this medication. It is essential for the nurse to focus on the most relevant and common adverse effects to ensure the client's understanding and safety.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in fetal heart rate (FHR) indicate uteroplacental insufficiency, possibly due to decreased oxygen supply to the fetus. Providing oxygen to the mother increases oxygen delivery to the fetus, improving oxygenation and potentially reversing the late decelerations. Other choices are incorrect: A could increase intra-abdominal pressure, worsening late decelerations. C can decrease placental perfusion. D is not indicated for late decelerations.