Nokea
Which of the following full-term babies requires immediate intervention?
- A. Baby with seesaw breathing.
- B. Baby with irregular breathing with 10-second apnea spells.
- C. Baby with coordinated thoracic and abdominal breathing.
- D. Baby with respiratory rate of 52.
Correct Answer: A
Rationale: Seesaw breathing indicates diaphragmatic dysfunction and requires urgent evaluation.
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A client is preparing to breastfeed her newborn son in the cross-cradle position. Which of the following actions should the woman make?
- A. Place a pillow in her lap.
- B. Position the head of the baby in her elbow.
- C. Put the baby on his back.
- D. Move the breast toward the mouth of the baby.
Correct Answer: A
Rationale: A pillow supports the baby and reduces strain.
A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk?
- A. Hemorrhage.
- B. Stroke.
- C. Endometritis.
- D. Hematoma.
Correct Answer: B
Rationale: DVT increases stroke risk due to clot migration.
A client is receiving an IV heparin drip at 16 mL/hr via an infusion pump for a diagnosis of deep vein thrombosis. The label on the 1/2 liter bag of D5W indicates 25,000 units of heparin have been added. How many units of heparin is the client receiving per hour? (Calculate to the nearest whole.)
- A. 800
- B. NA
- C. NA
- D. NA
Correct Answer: A
Rationale: Calculation: 25,000 units ÷ 500 mL × 16 mL = 800 units.
A nurse is teaching a mother how to care for her 3-day-old son's circumcised penis. Which of the following actions demonstrates that the mother has learned the information?
- A. The mother cleanses the glans with a cotton swab dipped in hydrogen peroxide.
- B. The mother covers the glans with antifungal ointment after rinsing off any discharge.
- C. The mother squeezes soapy water from the wash cloth over the glans.
- D. The mother replaces the dry sterile dressing before putting on the diaper.
Correct Answer: D
Rationale: Proper care involves keeping the area clean and dry, with a sterile dressing if necessary.
The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
- A. Sitz baths four times a day
- B. Use of only warm water with the sitz baths
- C. Topical anesthetic spray after perineal care
- D. Ice pack to the perineum for the first 24 hours
Correct Answer: A
Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.