Extract:

Multiple clients on the postpartum unit

Question 1 of 5

A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a puerperal infection?

A. A client who has a cesarean incision that is well-approximated with no drainage.B. A client who does not wash her hands between perineal care and breastfeeding.C. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration.D. A client who is not breastfeeding and is using measures to suppress lactation.

Correct Answer: C

Rationale: An erythematous episiotomy extended to a third-degree laceration increases infection risk due to the deeper tissue involvement and potential for bacterial growth.

Extract:

Laboring patient with an external fetal monitor showing late decelerations

Question 2 of 5

A nurse is caring for a laboring patient with an external fetal monitor. The nurse notices late decelerations on the monitor strip. What does the nurse interpret this as indicating?

A. Maternal bradycardiaB. Uteroplacental insufficiencyC. Umbilical cord compressionD. Fetal head compression

Correct Answer: B

Rationale: Late decelerations indicate uteroplacental insufficiency, reducing oxygen and nutrient transfer to the fetus.

Extract:

Newborn born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight

Question 3 of 5

A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. How should the nurse classify this neonate based on the weight and gestational age?

A. Low birth weightB. Appropriate for gestational ageC. Large for gestational ageD. Small for gestational age

Correct Answer: B

Rationale: A weight in the 60th percentile at 38 weeks classifies the neonate as appropriate for gestational age (10th-90th percentile).

Extract:

Child admitted with suspected rheumatic fever

Question 4 of 5

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?

A. This test will indicate if your child has rheumatic fever.B. This test will confirm if your child had a recent streptococcal infection.C. This test will indicate if your child has a therapeutic blood level of an aminoglycoside.D. This test will confirm if your child has immunity to streptococcal bacteria.

Correct Answer: B

Rationale: An ASO titer confirms recent streptococcal infection, a precursor to rheumatic fever, by detecting streptolysin O antibodies.

Extract:

Client in labor experiencing incomplete uterine relaxation between hypertonic contractions

Question 5 of 5

A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions. What adverse effect does the nurse recognize as a result of this contraction pattern?

A. Reduced fetal oxygen supplyB. Delayed cervical dilationC. Prolonged laborD. Increased maternal stress.

Correct Answer: B

Rationale: Incomplete uterine relaxation with hypertonic contractions can impede cervical dilation, slowing labor progression.