Nokea
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding is associated with Down Syndrome, which requires further evaluation by the provider. Single palmar creases are a physical characteristic commonly seen in infants with Down Syndrome. Reporting this to the provider allows for early intervention and appropriate management. Choices B, C, D, and E are incorrect because Down Syndrome (choice B) is not a clinical finding to report but rather a condition associated with single palmar creases. Rust-stained urine (choice C) may indicate hematuria but is not a common concern in newborns. Transient circumoral cyanosis (choice D) is a common finding in newborns that usually resolves on its own. Subconjunctival hemorrhage (choice E) is also a common and benign finding in newborns.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious postpartum complication. The nurse should report this to the provider immediately for further evaluation and intervention to prevent deterioration. Moderate lochia serosa (B) is expected 3 days postpartum. Heart rate of 89/min (C) and BP of 120/70 mm Hg (D) are within normal range for a postpartum client and do not require immediate reporting.
Which of the following findings should the nurse report to the provider?Select the 3 findings that should be reported.
- A. Uterine contractions
- B. Fetal heart rate
- C. Gestational age
- D. Vaginal examination
- E. Maternal blood pressure
Correct Answer: A,B,D
Rationale: The correct answers to report to the provider are A, B, and D.
A: Uterine contractions - Significant contractions could indicate preterm labor.
B: Fetal heart rate - Abnormal fetal heart rate can indicate fetal distress.
D: Vaginal examination - Risk of infection or cervical changes need provider evaluation.
C: Gestational age - Routine information, not typically requiring immediate provider notification.
E: Maternal blood pressure - Important but not typically urgent unless severely abnormal.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation
- B. Temperature
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps prevent aortocaval compression, a potential cause of hypotension after epidural anesthesia. When the client is lying on their back, the weight of the uterus can compress the vena cava, reducing venous return and cardiac output, leading to hypotension. Turning the client to a side-lying position relieves this compression, improving blood flow and helping to stabilize blood pressure.
Summary:
B: Applying oxygen may be beneficial in some cases, but it does not directly address the underlying cause of hypotension in this scenario.
C: Massaging the fundus is not indicated for hypotension following epidural anesthesia.
D: Assisting the client to empty their bladder may be important for overall comfort and prevention of complications, but it does not address the hypotension directly.