Nokea
Assessment: Fontanels soft, head molded with caput succedaneum, eyes symmetric, sclera yellow, dry mucous membranes, abdomen soft, bowel sounds present. Vital Signs: HR 154/min, RR 44/min, Temp 36.9°C. Diagnostic Results: Coombs positive, Glucose 50 mg/dL. Nurses' Notes: Term newborn, 39 weeks, Apgar 9/9, breastfeeding 3-4 times/day, voided once, no meconium.
Which of the following findings should the nurse report to the RN? Select all that apply.
- A. Sclera color
- B. Heart rate
- C. Respiratory rate
- D. Glucose level
- E. Coombs test result
- F. Head assessment finding
Correct Answer: A,E,G
Rationale: Yellow sclera, positive Coombs test, infrequent voiding/no meconium, and dry mucous membranes suggest jaundice, hemolysis, and dehydration, requiring reporting.
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A nurse is collecting data from a client who has hyperemesis gravidarum.
Which of the following findings should the nurse anticipate?
- A. Poor skin turgor
- B. Decreased pulse rate
- C. Increased fundal height
- D. Proteinuria
Correct Answer: A
Rationale: Poor skin turgor indicates dehydration, a common consequence of severe vomiting in hyperemesis gravidarum.
A nurse is caring for a client who inquires about available methods of contraception.
Which of the following actions should the nurse take?
- A. Collect a dietary history
- B. Perform unbiased teaching
- C. Select the best method of contraception for the client
- D. Assess the client's socioeconomic status.
Correct Answer: B
Rationale: Providing comprehensive, nonjudgmental education on all contraceptive methods allows the client to make an informed decision based on their preferences and needs.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Fetal heart tones 98 /min
- B. Foul smelling vaginal discharge
- C. Amniotic fluid with meconium noted
- D. Maternal temperature 38.3°C (101°F)
Correct Answer: A
Rationale: Fetal bradycardia (98/min) indicates distress, requiring immediate intervention due to possible cord prolapse after membrane rupture.
Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 to 3 hr.
- B. Give the newborn 30 mL of distilled water after each feeding
- C. Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
- D. Monitor the newborn's blood glucose level every 2 hr
Correct Answer: A
Rationale: Repositioning every 2-3 hours ensures all skin areas are exposed to phototherapy light, enhancing bilirubin breakdown.