63.Which of the following would be thepriority nursingdiagnosisfor a client with an ectopic pregnancy?a.Risk for infectionb.Painc.Knowledge Deficitd.Anticipatory Grieving64.

Before assessing the postpartum clientsuterus for firmness and positi on in relationto the umbilicus and midline, which of thefollowing should the nur se do first?a.Assess the vital signsb.Administer analgesiac.Ambulate her in the halld.Assist her to urinate65.Which of the following should the nurse dowhen a p rimipara who is lactating tells thenurse that she has sore nipples?a.Tell her to breast feed morefrequentlyb.Administer a narcotic before breastfeedingc.Encoura ge her to wear a nursingbrassiered.Use soap and water to clean thenipples66.The nurse assesses the vital signs of aclient, 4 hours postpartum that are asfollows: BP 90/60; temperature 100.4F;pulse 100 weak, thready; R 20 per minute.Which of t he following should the nurse dofirst?a.Report the temperature to thephysicianb. Recheck the blood pressure withanother cuff c.Assess the uterus for firmness and positiond.Determine the amount of lochia67.The nurse assesses the postpartumvagi nal discharge (lochia) on four clients.Which of the following assessments wouldw arrant notification of the physician?a.A dark red discharge on a 2-daypostpartum clientb.A pink to brownish discharge on aclient who is 5 days postpartumc.Almos t colorless to creamydischarge on a client 2 weeks afterdeliveryd.A bright red d ischarge 5 days afterdelivery68.A postpartum client has a temperature of 101.4F, with a uterus that is tender whenpalpated, remains unusually large, and notdesce nding as normally expected. Whichof the following should the nurse assessnext?a. Lochiab.Breastsc.Incisiond.Urine69.Which of the following is the priority focuso f nursing practice with the current earlypostpartum discharge?a.Promoting comfor t and restorationof healthb.Exploring the emotional status of the familyc.Facili tating safe and effective self-and newborn cared. Teaching about the importance of familyplanning 70.Which of the following actions would beleast effective in m aintaining a neutralthermal environment for the newborn?a.Placing infant under r adiantwarmer after bathingb.Covering the scale with a warmedblanket prior to wei ghingc.Placing crib close to nurserywindow for family viewingd.Covering the infa nts head with aknit stockinette71.A newborn who has an asymmetrical Mororeflex re sponse should be further assessedfor which of the following?a.Talipes equinovaru sb.Fractured claviclec.Congenital hypothyroidismd.Increased intracranial pressur e72.During the first 4 hours after a malecircumcision, assessing for which of th efollowing is the priority?a.Infectionb.Hemorrhagec.Discomfortd.Dehydration73.Th e mother asks the nurse. Whats wrongwith my sons breasts? Why are they soenlarged? W hish of the following wouldbe the best response by the nurse?a.The breast tissue is inflamed fromthe trauma experienced with birthb.A decrease in material hormones present before birth causesenlargement,c.You should discuss this with yourdoctor. It could be a malignancyd.The tissue has hypertrophiedwhile the baby was in the ut erus74.Immediately after birth the nurse notesthe following on a male newborn:res pirations 78; apical hearth rate 160BPM, nostril flaring; mild intercostalretrac tions; and grunting at the end of expiration. Which of the following shouldthe n urse do?a.Call the assessment data to thephysicians attentionb.Start oxygen per n asal cannula at 2L/min.