Nokea
Which of the following observations is expected when the nurse is assessing the gestational age of a neonate delivered at term?
- A. Ear lying flat against the head.
- B. Absence of rugae in the scrotum.
- C. Sole creases covering the entire foot.
- D. Square window sign angle of 90 degrees.
Correct Answer: C
Rationale: Sole creases covering the entire foot are characteristic of a term neonate, indicating full gestational maturity.
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A multigravid client in active labor at term suddenly sits up and says, 'I can't breathe! My chest hurts really bad!' The client's skin begins to turn a dusky gray color. After calling for assistance, which of the following should the nurse do next?
- A. Administer oxygen by face mask.
- B. Begin cardiopulmonary resuscitation.
- C. Administer intravenous oxytocin.
- D. Obtain an order for intravenous fibrinogen.
Correct Answer: A
Rationale: Sudden dyspnea, chest pain, and dusky skin suggest a possible pulmonary embolism or amniotic fluid embolism. Administering oxygen improves oxygenation while awaiting further intervention. CPR is premature, oxytocin is irrelevant, and fibrinogen is for coagulopathy.
The nurse on the night shift finds a multiparous client, 8 hours postpartum, drenched in perspiration. The client's temperature is 99°F (36.8°C), the pulse is 68 bpm, and the blood pressure is 120/80 mm Hg. Which of the following nursing diagnoses is a priority?
- A. Risk for infection (postpartum) related to birth trauma.
- B. Ineffective thermoregulation related to hormonal changes.
- C. Ineffective tissue perfusion: Renal related to the status of multiparity.
- D. Excess fluid volume related to normal postpartal diuresis.
Correct Answer: B
Rationale: Profuse sweating and normal vital signs suggest ineffective thermoregulation due to hormonal shifts, a common postpartum occurrence.
While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?
- A. Bronze-colored skin.
- B. Maculopapular chest rash.
- C. Urine specific gravity of 1.018.
- D. Absent Moro reflex.
Correct Answer: A
Rationale: Bronze-colored skin is a potential complication of phototherapy and should be reported to the health care provider.
A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan?
- A. Another method of contraception is needed until the sperm count is 0.
- B. Vasectomy is easily reversed if children are desired in the future.
- C. Vasectomy is contraindicated in males with prior history of cardiac disease.
- D. Vasectomy requires only a yearly follow-up once the procedure is completed.
Correct Answer: A
Rationale: After a vasectomy, another contraception method is needed until a follow-up semen analysis confirms a zero sperm count, ensuring sterility.
A client is considering the cervical cap. Which of the following statements by the nurse is accurate?
- A. The cervical cap can be left in place for up to 72 hours.
- B. The cervical cap does not require spermicide.
- C. The cervical cap requires a prescription and fitting.
- D. The cervical cap is highly effective for women who have given birth.
Correct Answer: C
Rationale: The cervical cap requires a prescription and fitting by a healthcare provider for proper use. It can be left in place for up to 48 hours, requires spermicide, and is less effective for women who have given birth.