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A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms due to drug discontinuation at birth. Vomiting is a common withdrawal manifestation in newborns due to the sudden absence of the drug. Large for gestational age (choice A) is not typically associated with SSRI withdrawal. Hyperglycemia (choice B) and bradypnea (choice C) are not typical withdrawal symptoms of SSRIs. Therefore, the nurse should identify vomiting as an indication of withdrawal from an SSRI in the newborn.
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A nurse in an antepartum clinic is providing weeks of gestation. Upon reviewing the following findings should the nurse report to the provider? (Click on the 'Exhibit' button for additional information about the client. There are three tabs that contain separate categories of data.)
- A. 1-hr glucose tolerance test
- B. Hematocrit
- C. Fundal height measurement
- D. Fetal heart rate (FHR)
Correct Answer: D
Rationale: The correct answer is D: Fetal heart rate (FHR). The nurse should report any abnormal findings related to fetal well-being to the provider. Monitoring the FHR is crucial to assess the baby's status and can indicate potential issues such as fetal distress. In this scenario, if the FHR is abnormal (e.g., too high or too low), it could signal a problem that needs immediate attention.
A: 1-hr glucose tolerance test - This is typically done to screen for gestational diabetes and is not directly related to fetal well-being.
B: Hematocrit - This measures the volume percentage of red blood cells in blood and is more related to maternal health.
C: Fundal height measurement - This assesses fetal growth and position, but abnormal findings may not require immediate provider notification unless significant deviations are noted.
In summary, the other choices are not as time-sensitive or directly indicative of fetal distress as the FHR, making D the correct answer in this context.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus.
- B. Cervical laceration.
- C. Excess vaginal bleeding.
- D. Increased afterbirth cramping.
- E. Increased maternal temperature.
Correct Answer: A, C
Rationale: The correct choices for administering oxytocin are A (flaccid uterus) and C (excess vaginal bleeding). Oxytocin is indicated to help contract the uterus, reducing bleeding and preventing postpartum hemorrhage. A flaccid uterus indicates poor uterine tone, which can lead to increased bleeding. Excess vaginal bleeding also indicates the need for oxytocin to aid in uterine contraction. Choices B, D, and E are incorrect. Cervical laceration does not directly impact the need for oxytocin administration. Increased afterbirth cramping is a normal postpartum finding and does not necessarily require oxytocin. Increased maternal temperature is not a direct indication for oxytocin administration.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions.
- B. Acrocyanosis.
- C. Overlapping suture lines.
- D. Head circumference 33 cm (13 in).
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions indicate respiratory distress in a newborn, which can be a serious issue requiring immediate medical attention. Acrocyanosis (choice B) is a common finding in newborns and is not concerning. Overlapping suture lines (choice C) can be normal in newborns and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) is within the normal range for a newborn.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia.
- B. Increased feeding.
- C. Hyperthermia.
- D. Respiratory distress.
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent.
- B. Active.
- C. Early.
- D. Descent.
Correct Answer: D
Rationale: The correct answer is D: Descent. At 9 cm dilation, the client is in the second stage of labor, which consists of the descent and birth of the baby. Increasing rectal pressure indicates fetal descent and impending birth. Contractions 2-3 min apart lasting 80-90 seconds are characteristic of the active phase of the second stage of labor. The passive descent phase occurs earlier when the cervix is not fully dilated. The early phase is part of the first stage of labor. Active labor typically begins when the cervix is around 6 cm dilated. Therefore, D is the correct choice as it aligns with the client's symptoms and stage of labor progression.