Nokea
Which of the following best identifies the reason for assessing a neonate weighing 1,500 g at 32 weeks' gestation for retinopathy of prematurity (ROP)?
- A. The neonate is at risk because of multiple factors.
- B. Oxygen is being administered at a level of $21%.
- C. The neonate was alkalotic immediately after birth.
- D. Phototherapy is likely to be ordered by the pediatrician.
Correct Answer: A
Rationale: Preterm neonates, especially those with low birth weight and receiving oxygen, are at risk for ROP due to immature retinal development.
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A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepregnant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is:
- A. 4 weeks.
- B. 6 weeks.
- C. 8 weeks.
- D. 12 weeks.
Correct Answer: D
Rationale: Returning to prepregnant weight typically takes about 12 weeks with proper diet and exercise.
A primiparous client has just delivered her baby. The physician has informed the labor nurse that he believes the uterus has inverted. Which of the following would help to confirm this diagnosis? Select all that apply.
- A. Hypotension.
- B. Gush of blood from the vagina.
- C. Intense, severe, tearing type of abdominal pain.
- D. Uterus is hard and in a constant state of contraction.
- E. Inability to palpate the uterus.
- F. Diaphoresis.
Correct Answer: A,E
Rationale: Uterine inversion is characterized by the uterus turning inside out, often leading to hypotension (due to shock) and inability to palpate the fundus abdominally. A gush of blood may occur but is not specific, severe pain is less common, the uterus is not typically hard, and diaphoresis is a secondary symptom.
A client at 15 weeks' gestation is admitted with dark brown vaginal bleeding and continuous nausea and vomiting. Her blood pressure is 142/98 and fundal height is 19 cm. The nurse should prepare to do which of the following?
- A. Transfer the client to the antenatal unit.
- B. Keep the client NPO for 24 hours.
- C. Administer magnesium sulfate.
- D. Obtain an ultrasound.
Correct Answer: D
Rationale: Ultrasound confirms the diagnosis of a hydatidiform mole.
Assessment of a primigravid client in active labor who has had no analgesia or anesthesia reveals complete cervical effacement, dilation of 8 cm, and the fetus at 0 station. The nurse should expect the client to exhibit which of the following behaviors during this phase of labor?
- A. Excitement.
- B. Loss of control.
- C. Numbness of the legs.
- D. Feelings of relief.
Correct Answer: B
Rationale: During the transition phase (8–10 cm dilation), primigravid clients without analgesia often experience intense contractions and may feel overwhelmed, leading to a perceived loss of control. Excitement is more common in early labor, numbness of the legs is associated with epidural anesthesia, and feelings of relief typically occur after delivery.
Four days after a vaginal delivery, the client visits the clinic complaining of excessive lochia rubra with clots. The physician orders methylergonovine maleate (Methergine), 0.2 mg intramuscularly. Before administering this drug, the nurse should assess:
- A. Blood pressure.
- B. Pulse rate.
- C. Breath sounds.
- D. Bowel sounds.
Correct Answer: A
Rationale: Methylergonovine can cause hypertension, so blood pressure assessment is essential before administration.