Question

A nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?

Answer 1

Correct Answers:

Bilirubin 14.0 mg/dL (1.0 to 12.0 mg/dL)

Rationale :

🎇A newborn with a cephalohematoma is at increased risk for hyperbilirubinemia due to the breakdown of red blood cells trapped in the hematoma.

🎇 As the body metabolizes the pooled blood, bilirubin levels rise, which can lead to jaundice.

🎇 A bilirubin level of 14.0 mg/dL exceeds the expected reference range (1.0–12.0 mg/dL) and is an anticipated finding.

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Answer 2

Correct Answers:

BUN 30 mg/dL (10 to 20 mg/dL)

Rationale :

🌐 In preeclampsia, renal perfusion is impaired, which can result in elevated blood urea nitrogen (BUN) due to decreased renal clearance.

🌐 A BUN of 30 mg/dL (normal: 10–20 mg/dL) reflects renal involvement, a key complication of this hypertensive disorder.

🌐The other listed lab values are either low or not typical for preeclampsia.

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Answer 3

Correct Answers:

Excessive high-pitched cry

Rationale :

🧩A high-pitched, excessive cry is a hallmark sign of neonatal abstinence syndrome (NAS), often seen in infants born to mothers who used opioids or methadone during pregnancy.

🧩Other common signs include irritability, tremors, feeding difficulty, and hypertonia.

🧩Acrocyanosis and respiratory rate of 50/min are normal findings in newborns.

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Answer 4

Correct Answers:

Respiratory rate 11 min

Rationale :

🦠A respiratory rate of 11/min is below the safe threshold for clients receiving magnesium sulfate, which can cause respiratory depression if serum levels are high.

🦠 The nurse should report this immediately.

🦠Urine output and BP are within acceptable limits; reflexes at 2+ are normal.

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Answer 5

Correct Answers:

Recommend a support group for the client to attend.

Rationale :

🎲Addressing body image concerns following a mastectomy requires psychosocial support.

🎲 Encouraging the client to join a support group provides emotional validation and connection to others with similar experiences.

🎲Discouraging feelings or shifting focus away from their concern is dismissive.

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Answer 6

Correct Answers:

Instruct the client to wash their hands prior to breastfeeding.
Teach the client about proper latching-on techniques.
Encourage the client to alternate breastfeeding with formula feeding.

Rationale :

✔️ Instruct the client to wash their hands prior to breastfeeding

✴ Hand hygiene is a fundamental infection control measure that reduces the risk of spreading bacteria to the breast tissue and infant.

✴In the context of mastitis, where breast tissue is already inflamed and potentially infected, maintaining clean hands before touching the breast or baby is essential to prevent worsening of the condition or transmitting bacteria to the infant.

✴Proper hygiene also reduces the risk of abscess formation and ensures safe breastfeeding.

✔️ Teach the client about proper latching-on techniques

✴ Improper latching is a leading cause of nipple trauma, which can predispose a client to mastitis by creating portals for bacterial entry.

✴Educating the client on how to achieve a deep latch helps prevent cracked or bleeding nipples and promotes effective milk drainage, which reduces the risk of milk stasis—another key factor in mastitis development.

✴ Proper latching also improves breastfeeding efficiency and infant satisfaction.

✔️ Encourage the client to allow their nipples to air dry after feedings

✴ Allowing nipples to air dry helps prevent moisture accumulation, which can promote bacterial and fungal overgrowth.

✴ Moist environments under nursing pads or bras can exacerbate skin irritation or delay healing of nipple cracks or soreness.

✴ Air drying supports skin integrity and comfort during the healing process and is part of non-pharmacologic care for breastfeeding complications.

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Answer 7

Correct Answers:

Null parity
History of breastfeeding
Use of postmenopausal estrogen

Rationale :

✔️ Nulliparity

🧠 Nulliparity—meaning the client has never carried a pregnancy to term—is a well-documented risk factor for ovarian cancer.

🧠The underlying mechanism relates to continuous ovulation over time, which increases genetic mutations and epithelial disruption in the ovaries.

🧠Pregnancy and breastfeeding provide periods of ovulatory suppression, which reduce this cumulative risk.

🧠Therefore, women who have not been pregnant are exposed to more lifetime ovulatory cycles, heightening the risk of malignancy.

✔️ History of breast cancer

🧠 A personal or family history of breast cancer, especially when linked to BRCA1 or BRCA2 genetic mutations, significantly increases a woman’s lifetime risk of ovarian cancer.

🧠These mutations are associated with hereditary breast and ovarian cancer (HBOC) syndrome.

🧠A client with a prior diagnosis of breast cancer should be closely monitored for ovarian malignancies, particularly if she has a positive family history or underwent early-onset breast cancer.

✔️ Use of postmenopausal estrogen

🧠 Estrogen-only hormone replacement therapy (HRT), when used after menopause without balancing progesterone, has been associated with an increased risk of ovarian cancer, particularly serous carcinoma.

🧠 The hormone promotes proliferation of ovarian epithelial tissue, potentially triggering malignant changes over prolonged use.

🧠 This risk is more pronounced in women who have used estrogen therapy for more than 5 years without uterine protection.

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Answer 8

Correct Answers:

Sliced apples

Rationale :

🔷Clients with phenylketonuria (PKU) must follow a low-phenylalanine diet, avoiding high-protein foods such as peanut butter, milk, and eggs.

🔷Apples are safe because they are low in protein and phenylalanine.

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Answer 9

Correct Answers:

Discontinue the infusion of oxytocin.

Rationale :

💡Variable decelerations are often due to cord compression, and the priority is to reduce uterine contractions that worsen the compression.

💡Stopping oxytocin decreases contraction frequency and improves fetal oxygenation.

💡While amnioinfusion and exams may follow, stopping oxytocin is the first priority.

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Answer 10

Correct Answers:

"This shot may be given after birth to protect future pregnancies:

Rationale :

🔦Rho(D) immune globulin is administered to Rh-negative mothers after delivery only if the baby is Rh-positive to prevent isoimmunization in future pregnancies.

🔦 It is safe with vaccines, and not needed if both parents are Rh-negative.

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QLexNursing

1 :
A nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?

2 :
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?

3 :
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

4 :
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

5 :
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?

6 :
A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

7 :
A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply)

8 :
A nurse providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include in the teaching?

9 :
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

10 :
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

QLexNursing

1 : A nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?

2 : A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?

3 : A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

4 : A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

5 : A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?

6 : A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

7 : A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply)

8 : A nurse providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include in the teaching?

9 : A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

10 : A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?

1 :
A nurse is reviewing the laboratory results of a newborn who is 32 hours old and has a cephalohematoma. Which of the following findings should the nurse expect as a result of this condition?

2 :
A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse expect?

3 :
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?

4 :
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?

5 :
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?

6 :
A nurse is planning care for a client who is breastfeeding and has mastitis. Which of the following interventions should the nurse include? (Select all that apply.)

7 :
A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include? (Select all that apply)

8 :
A nurse providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include in the teaching?

9 :
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?

10 :
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?