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Which of the following subjects should the nurse include when teaching the mother of a neonate diagnosed with retinopathy of prematurity (ROP) about possible treatment for complications?
- A. Laser therapy.
- B. Common medium (Intal) eye drops.
- C. Frequent testing for glaucoma.
- D. Corneal transplants.
Correct Answer: A
Rationale: Laser therapy is a common treatment for severe ROP to prevent retinal detachment.
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The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results?
- A. Platelets 200,000 mm3.
- B. Lactate dehydrogenase(LDH)> 200 units/L.
- C. Uric acid 3 mg/dL.
- D. Aspartate aminotransferase(AST) 15 units/L.
Correct Answer: B
Rationale: Elevated LDH indicates possible hemolysis in HELLP syndrome.
Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?
- A. Pain related to episiotomy and exhaustive pushing efforts.
- B. Anxiety related to inability to move legs and toes.
- C. Risk for injury related to epidural anesthesia.
- D. Excess fluid volume overload related to labor process and intravenous fluids.
Correct Answer: C
Rationale: Epidural anesthesia poses a risk for injury due to potential complications like hypotension or impaired mobility, making this the priority post-delivery. Pain, anxiety, and fluid overload are secondary concerns.
A septic preterm neonate's I.V. was removed due to infiltration. While restarting the I.V., the nurse should carefully assess the neonate for:
- A. Fever.
- B. Hypoglycemia.
- C. Tachycardia.
Correct Answer: C
Rationale: Tachycardia can indicate pain, stress, or cardiovascular compromise during I.V. insertion, especially in a septic preterm neonate.
One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?
- A. Continue to monitor the client's fundus every 15 minutes.
- B. Ask the physician for an order for methylergonovine (Methergine).
- C. Immediately notify the physician of the client's symptoms.
- D. Change the client's perineal pads every 15 minutes.
Correct Answer: C
Rationale: Large clots and bright red bleeding post-delivery suggest possible uterine atony or retained placental fragments, requiring immediate physician notification for intervention. Monitoring, requesting medication, or changing pads are secondary actions.
A 27-year-old primigravid client with insulin-dependent diabetes at 34 weeks' gestation undergoes a nonstress test, the results of which are documented as reactive. The nurse should tell the client that the test results indicate which of the following?
- A. A contraction stress test is necessary.
- B. The nonstress test should be repeated.
- C. Chorionic villus sampling is necessary.
- D. There is evidence of fetal well-being.
Correct Answer: D
Rationale: Reactive nonstress test indicates fetal well-being.