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Questions 149

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Question 1 of 5

The nurse is caring for a client admitted to labor and delivery. The nurse is aware that the infant is in distress if she notes:

Correct Answer: B

Rationale: Absent variability on the fetal monitor indicates fetal distress, suggesting compromised oxygenation.

Question 2 of 5

Four days after delivery, a client develops complications of postpartal hemorrhage. The most common cause of late postpartal hemorrhage is:

Correct Answer: B

Rationale: Retained placental fragments are the most common cause of late postpartum hemorrhage, as they prevent proper uterine contraction and hemostasis.

Question 3 of 5

Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:

Correct Answer: C

Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.

Question 4 of 5

A newborn is diagnosed with congenital syphilis. Classic signs of congenital syphilis are:

Correct Answer: B

Rationale: Congenital syphilis presents with rhinitis (‘snuffles'), maculopapular rash, and hepatosplenomegaly due to systemic infection.

Question 5 of 5

A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:

Correct Answer: B

Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.

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