Nokea
Which of the following characteristics would indicate true labor in a client?
- A. Contractions are irregular and painless
- B. Fetus moves to an anterior position
- C. Bloody show is not present
- D. Contractions are regular in frequency
Correct Answer: D
Rationale: True labor is characterized by regular contractions that increase in intensity and frequency. These contractions result in cervical dilation and effacement, indicating the onset of labor.
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A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
- A. Maintain an eye mask over the newborn's eyes
- B. Feed the newborn every hour
- C. Monitor the newborn's temperature
- D. Administer vitamin K
Correct Answer: A
Rationale: Phototherapy is used to reduce bilirubin levels in newborns with jaundice. However, the intense light can cause damage to the newborn's corneas and retinas. The use of an eye mask protects the infant's eyes while allowing the therapy to proceed. Regular monitoring of the newborn's temperature and hydration status is also important, but the eye mask is a key protective measure.
A home care nurse is following up with a postpartum client. Which of the following is a risk factor that places this client at risk for postpartum depression?
- A. History of anxiety
- B. Socioeconomic status
- C. Hormonal changes with a rapid decline in estrogen and progesterone
- D. Support from family members
Correct Answer: C
Rationale: Postpartum depression can be triggered by various factors, but one of the strongest predictors is a rapid drop in estrogen and progesterone levels following childbirth. These hormonal changes can affect mood regulation, making some women more vulnerable to depression during the postpartum period.
A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?
- A. Non-Hodgkin's lymphoma
- B. Endometriosis
- C. Breast cancer
- D. Polycystic ovary syndrome
Correct Answer: C
Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow.
A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5° C (97.7° F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct Answer: B
Rationale: Nasal flaring can indicate respiratory distress and should be reported immediately for further evaluation.
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1° C (96.9° F)
- D. Excessive sleeping
Correct Answer: B
Rationale: Moderate tremors of the extremities are a common sign of opioid withdrawal in newborns. Other signs may include irritability, feeding difficulties, and gastrointestinal disturbances.