Nokea
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale: The correct answers are A, B, C, and G. A Coombs test result should be reported as it indicates the presence of antibodies that can cause hemolytic anemia. Mucous membrane assessment is crucial for detecting hydration status and oxygenation. Intake and output monitoring helps assess kidney function and fluid balance. Sclera color can indicate liver function or jaundice. Choices D, E, and F are not necessarily critical findings to report urgently to the provider in most cases. Monitoring respiratory rate, heart rate, and head assessment findings are important but may not require immediate provider notification unless there are significant abnormalities.
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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. This is crucial for preventing infection due to the leakage of cerebrospinal fluid, which can lead to meningitis. Antibiotics will help reduce the risk of infection until surgical repair can be done. Monitoring rectal temperature (B) is not directly related to addressing the myelomeningocele. Cleansing the site with povidone-iodine (C) may further irritate the area. Surgical closure (D) should not be delayed, as infection risk is high.
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A. Emptying the bladder before amniocentesis helps prevent injury to the bladder during the procedure. This statement shows understanding of the importance of bladder emptying for safety and accuracy.
B: Incorrect. The client is typically lying on their back during amniocentesis.
C: Incorrect. The client is awake during the procedure.
D: Incorrect. Fasting is not required for amniocentesis.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by symptoms such as irritability, high-pitched crying, tremors, and poor feeding due to withdrawal from substances the mother used during pregnancy. Excessive crying is a common manifestation of this syndrome. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may indicate other neurological or developmental issues.
A nurse is preparing to perform Leopold maneuvers on a client who is at 36 weeks of gestation. Identify the sequence of actions the nurse should take.
- A. Instruct the client to empty their bladder.
- B. Position the client supine with knees flexed and place a small, rolled towel under one of their hips.
- C. Palpate the fetal part positioned in the fundus.
- D. Palpate the fetal parts along both sides of the uterus.
Correct Answer: A, B, C, D
Rationale: Action to Take: A, B; Potential Condition: C; Parameter to Monitor: D, E.
The correct sequence of actions for performing Leopold maneuvers includes:
A) Instruct the client to empty their bladder to enhance visualization and palpation accuracy.
B) Position the client supine with knees flexed to provide access and comfort for the client during the procedure.
C) Palpate the fetal part positioned in the fundus to determine the baby's presentation and position.
D) Palpate the fetal parts along both sides of the uterus to assess the location and movement of the fetus.
It is important to follow these steps to accurately assess the fetal position and presentation. Other choices are incorrect as they do not align with the standard procedure for Leopold maneuvers.
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs to rotate the pelvis, allowing the baby's shoulder to dislodge. This action enlarges the pelvic outlet, facilitating the delivery of the baby. Applying pressure to the fundus (A) or pressing on the suprapubic area (B) are not appropriate interventions for shoulder dystocia. Moving the client onto their hands and knees (C) may be helpful in some cases but is not the initial step for the McRoberts maneuver.