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Newborn with a suspected condition.
Which of the following findings should the nurse identify as manifestations of the newborn's suspected condition?
- A. Mother's report of feedings.
- B. Oral mucosa findings.
- C. Respiratory findings.
- D. Temperature change.
Correct Answer: B,C
Rationale: Oral mucosa changes (B), such as pallor or cyanosis, may occur due to hypoxia or circulatory compromise. Respiratory changes (C), including tachypnea or retractions, are significant manifestations of stress or pulmonary involvement in neonatal conditions like asphyxia.
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Client reporting severe abdominal pain.
A nurse in the labor and delivery triage unit reviews the electronic medical record (EMR) of a client reporting severe abdominal pain. Which of the following findings is most consistent with abruptio placenta?
- A. Low uterine tone with mild vaginal bleeding.
- B. Rigid uterine tone with dark vaginal bleeding.
- C. Soft uterine tone with painless vaginal bleeding.
- D. Low uterine tone with absence of vaginal bleeding.
Correct Answer: B
Rationale: Rigid uterine tone with dark vaginal bleeding is a hallmark of abruptio placenta. The rigidity arises from blood pooling behind the placenta, causing uterine muscle contraction. Dark vaginal bleeding occurs as the blood is often concealed and clotted before expulsion.
Client reports feeling well, findings include: General: No acute distress. Cardiovascular: No murmur or rub. Respiratory: Bilateral breath sounds clear. Abdomen: Fundal height 38 cm. Genitourinary: Purulent cervical discharge.
A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
Four postpartum clients: 1 day ago needs Rh(D) immune globulin, 3 days ago reports breast fullness, 12 hours ago reports increased urinary output, 8 hours ago saturating a perineal pad every hour.
A nurse on a postpartum unit is receiving change-of-shift report for four clients. Which of the following clients should the nurse see first?
- A. A client who gave birth 1 day ago and needs Rh(D) immune globulin.
- B. A client who gave birth 3 days ago and reports breast fullness.
- C. A client who gave birth 12 hours ago and reports an increase in urinary output.
- D. A client who gave birth 8 hours ago and is saturating a perineal pad every hour.
Correct Answer: D
Rationale: Saturating a perineal pad every hour 8 hours postpartum indicates heavy vaginal bleeding, potentially signifying postpartum hemorrhage, a life-threatening condition requiring immediate evaluation and intervention.
Newborn who is 48 hr old and is experiencing opioid withdrawals.
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 result from central nervous system irritability during withdrawal. Elevated norepinephrine levels lead to excessive stimulation, causing tremors and jitteriness.
Client at 33 weeks of gestation with preeclampsia.
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?
- A. BUN level of 30 mg/dL (normal range: 10 to 20 mg/dL).
- B. Hemoglobin level of 9.9 g/dL (normal range: 11 to 16 g/dL).
- C. Serum uric acid level of 2.5 mg/dL (normal range: 2.7 to 7.3 mg/dL).
- D. Casual blood glucose level of 228 mg/dL (normal range: less than 200 mg/dL).
Correct Answer: A
Rationale: A BUN level of 30 mg/dL is above the normal range of 10 to 20 mg/dL. Elevated BUN is consistent with renal involvement in preeclampsia, which is caused by vascular constriction and reduced renal perfusion.