Nokea
While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?
- A. Conjunctivitis
- B. Bronze skin discoloration
- C. Sunken fontanels
- D. Maculopapular skin rash
Correct Answer: C
Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention.
Incorrect choices:
A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration.
B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue.
D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.
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A client who is postpartum and has thrombophlebitis requires nursing interventions. Which of the following nursing interventions should the nurse recommend?
- A. Apply cold compresses to the affected extremity
- B. Massage the affected extremity
- C. Allow the client to ambulate
- D. Measure leg circumferences
Correct Answer: D
Rationale: The correct answer is D - Measure leg circumferences. This is important in assessing for changes in swelling, which can indicate worsening thrombophlebitis. Monitoring leg circumferences helps in early detection of complications like deep vein thrombosis. Applying cold compresses (A) can worsen vasoconstriction, massage (B) can dislodge clots, and allowing ambulation (C) can increase the risk of clot migration.
During the third trimester of pregnancy, which of the following findings should a nurse recognize as an expected physiologic change?
- A. Gradual lordosis
- B. Increased abdominal muscle tone
- C. Posterior neck flexion
- D. Decreased mobility of pelvic joints
Correct Answer: A
Rationale: The correct answer is A: Gradual lordosis. During the third trimester, the growing uterus shifts the center of gravity forward, leading to an increased lumbar curvature known as lordosis. This change helps maintain balance and support the extra weight. Increased abdominal muscle tone (B) is not an expected finding as abdominal muscles tend to stretch and weaken during pregnancy. Posterior neck flexion (C) is not a common physiologic change during the third trimester. Decreased mobility of pelvic joints (D) is incorrect as hormonal changes during pregnancy actually increase flexibility in the pelvic joints to prepare for childbirth.
A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?
- A. Moderate lochia rubra
- B. Excessive lochia serosa
- C. Light lochia rubra
- D. Scant lochia serosa
Correct Answer: A
Rationale: The correct answer is A: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.
A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
- A. Your baby will have excess baby fat.
- B. Your baby will have flat areola without breast buds.
- C. Your baby's heels will easily move to his ears.
- D. Your baby's skin will have a leathery appearance.
Correct Answer: D
Rationale: The correct answer is D because a baby who is postmature may have dry, cracked, and peeling skin, leading to a leathery appearance due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa diminishes over time. Choice A is incorrect because excess baby fat is not a typical characteristic of postmaturity. Choice B is incorrect as flat areola without breast buds is not a common feature of postmaturity. Choice C is incorrect as the ability to easily move heels to ears is a sign of flexibility and does not specifically relate to postmaturity.
A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?
- A. I will keep the baby's head elevated while feeding.
- B. I will allow the baby to burp several times during each feeding.
- C. I will tilt the bottle to prevent air from entering as the baby sucks.
- D. My baby will have soft, formed yellow stools.
Correct Answer: C
Rationale: The correct answer is C. Tilt the bottle to prevent air from entering as the baby sucks is incorrect. It is important not to tilt the bottle as it can cause the baby to swallow air, leading to gas and discomfort. A: Keeping the baby's head elevated helps prevent choking. B: Allowing the baby to burp reduces gas and discomfort. D: Soft, formed yellow stools indicate a healthy digestive system. Thus, C is the only statement that may lead to issues and requires further instruction.