Nokea
A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?
- A. Fetal heart rate irregularities.
- B. Whitish vaginal discharge.
- C. Rapidly dropping human chorionic gonadotropin (hCG) levels.
- D. Excessive uterine enlargement.
Correct Answer: D
Rationale: Excessive uterine enlargement is a key sign of hydatidiform mole due to trophoblastic tissue overgrowth. Fetal heart rate irregularities are absent as there's typically no viable fetus, and hCG levels are high, not dropping. Bleeding, not whitish discharge, is common.
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A nurse is caring for a newborn immediately following delivery. After assuring a patent airway, which of the following actions should be the nurse's priority?
- A. Dry the newborn.
- B. Administer phytonadione IM.
- C. Document the Apgar score.
- D. Apply identification bands.
Correct Answer: A
Rationale: Drying the newborn prevents cold stress by reducing evaporative heat loss, which can lead to hypoxia and other complications. Administering phytonadione, documenting the Apgar score, and applying identification bands are important but not immediate priorities compared to thermoregulation.
A nurse is assisting with the care of a newborn 1 hr following birth. Select the 5 findings that the nurse should report to the provider.
- A. Temperature.
- B. Respiratory findings.
- C. Serum glucose.
- D. Hematocrit.
- E. White blood cell count.
- F. Hemoglobin
- G. Heart rate.
Correct Answer: B,C,D,F,G
Rationale: Respiratory issues post-ventilation, hypoglycemia risk from abruptio placenta, potential anemia (hematocrit, hemoglobin), and heart rate abnormalities from fetal distress require reporting.
What is the most significant risk factor for clubfoot?
- A. Smoking
- B. Trauma during pregnancy
- C. Hypertension
- D. Decreased circulation
Correct Answer: A
Rationale: Maternal smoking during pregnancy is strongly associated with clubfoot, likely affecting fetal muscle and tendon development. Trauma, hypertension, and decreased circulation lack evidence as significant risk factors for this congenital condition.
A nurse is reinforcing discharging teaching with a client who is 2 days postpartum. Which of the following statements should the nurse include in the teaching?
- A. If you give formula to your newborn, expect at least one stool every 3 days.
- B. If you breastfeed your newborn, expect two to three stools per day.
- C. You should feed your newborn formula every 2 hours.
- D. You should breastfeed your newborn five to seven times each day.
Correct Answer: B
Rationale: Breastfed newborns typically have 2-3 soft stools daily. Formula-fed babies stool daily, not every 3 days. Feeding should be on demand (8-12 times/day for breastfeeding), not on strict schedules.
What is perinatal injury?
- A. Injury sustained to the perineum during birth.
- B. Traumatic injury to the mother during pregnancy.
- C. Traumatic injury to a fetus.
- D. Injury sustained surrounding birth.
Correct Answer: D
Rationale: Perinatal injury occurs around birth, affecting the newborn due to labor forces or interventions, like fractures or nerve damage. Perineal, maternal, or fetal injuries are distinct categories.