Nokea
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
- A. Red reflex in the eyes.
- B. Expiratory grunt.
- C. Respiratory rate of 45 breaths/minute.
- D. Prominent xiphoid process.
Correct Answer: B
Rationale: An expiratory grunt is a sign of respiratory distress and warrants immediate notification of the pediatrician.
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A nurse and an LPN are working in the labor and delivery unit. Of the following assessments and interventions that must be done immediately, which should the nurse assign to the LPN?
- A. Complete an initial assessment on a client.
- B. Increase the oxytocin (Pitocin) rate on a laboring client.
- C. Perform a straight catheterization for protein analysis.
- D. Assess a laboring client for a change in labor pattern.
Correct Answer: C
Rationale: An LPN can perform a straight catheterization for protein analysis, a technical task within their scope. Initial assessments, oxytocin adjustments, and labor pattern assessments require RN judgment and expertise.
Fifteen minutes after a client experiences an eclamptic seizure, the nurse should assess the client for which of the following?
- A. Polyuria.
- B. Facial flushing.
- C. Hypotension.
- D. Uterine contractions.
Correct Answer: D
Rationale: Uterine contractions should be assessed post-seizure to evaluate labor status.
A full-term client is admitted for an induction of labor. The health care provider has assigned a Bishop score of 10. Which drug would the nurse anticipate administering to this client?
- A. Oxytocin (Pitocin) 10 units in 500 mL D5W.
- B. Prostaglandin gel (Prepidil) 0.5 mg.
- C. Misoprostol (Cytotec) 50 mcg P.O.
- D. Dinoprostone (Cervidil) 10 mg.
Correct Answer: A
Rationale: A Bishop score of 10 indicates a favorable cervix for induction, so oxytocin (Pitocin) is appropriate to initiate contractions. Prostaglandins (Prepidil, Cervidil, Cytotec) are used for cervical ripening when the cervix is unfavorable.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
A client asks about the effectiveness of male condoms. Which of the following responses by the nurse is accurate?
- A. They are 100% effective in preventing pregnancy.
- B. They are highly effective when used correctly.
- C. They require a prescription.
- D. They are less effective than the withdrawal method.
Correct Answer: B
Rationale: Male condoms are highly effective when used correctly, with a low failure rate. They are not 100% effective, do not require a prescription, and are more effective than the withdrawal method.