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A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. In newborns of mothers with gestational diabetes mellitus, hypoglycemia can occur due to the abrupt cessation of the maternal glucose supply. Jitteriness is a common manifestation of hypoglycemia in newborns. This is because the brain is highly dependent on glucose for energy, and low blood sugar levels can affect neurological function, leading to symptoms like jitteriness. Abdominal distention, petechiae, and increased muscle tone are not typical manifestations of hypoglycemia in newborns with a history of maternal gestational diabetes mellitus.
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A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: "How much protein do you eat in a day?" This question is important because as a vegan, the client may have a higher risk of protein deficiency due to the lack of animal protein in their diet. By asking about their protein intake, the nurse can assess if the client is meeting their protein needs for a healthy pregnancy.
Choice B, asking about a Vitamin C supplement, is incorrect as Vitamin C deficiency is not typically a concern for vegans and is not specifically related to gestational nutrition. Choice C, suggesting shellfish, is incorrect as it goes against the client's vegan dietary preferences. Choice D, asking about the last time the client ate meat, is also incorrect as it is not relevant to assessing their current dietary intake as a vegan.
Which stage of labor is characterized by the delivery of the placenta?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: C
Rationale: The correct answer is C: Third stage. This stage is characterized by the delivery of the placenta. It occurs after the baby is born (second stage) and involves the detachment and expulsion of the placenta from the uterus. The first stage is characterized by cervical dilation and effacement, while the fourth stage is the immediate postpartum period. The second stage is focused on the actual birth of the baby. Therefore, the delivery of the placenta specifically occurs in the third stage of labor.
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 inadequate energy supply to respiratory muscles. Hypertonia (choice A) is not a typical manifestation of hypoglycemia. Increased feeding (choice B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice C) is not directly related to hypoglycemia. Therefore, the most appropriate choice indicating hypoglycemia in this scenario is respiratory distress.
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Correct Answer: C - Hypotension
Rationale: Opioid analgesics can cause hypotension as a side effect by vasodilation and reduced cardiac output. The epidural route can further exacerbate this effect due to the potential spread of the medication to sympathetic nerves, resulting in vasodilation and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications such as decreased tissue perfusion and potential cardiovascular collapse.
Incorrect Choices:
A: Hyperglycemia - Opioids do not typically cause hyperglycemia.
B: Bilateral crackles - Crackles are not a common adverse effect of opioids.
D: Polyuria - Opioids do not usually cause polyuria.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C: "The car seat should be positioned in the car at a 45-degree angle." This is correct because newborns and premature babies (delivered at 38 weeks) have less muscle tone and are at risk of airway compromise if the head falls forward in the car seat. Placing the car seat at a 45-degree angle helps keep the baby's airway open and prevents slumping.
A: "I can use a sleep sack to keep my baby warm in the car seat." - This is incorrect as bulky clothing or blankets should not be used in the car seat as they can compress in a crash and create a loose harness fit.
B: "My baby will need a car seat challenge test before discharge." - This is incorrect as car seat challenge tests are usually done for premature infants born before 37 weeks.
D: "When my baby is 1 year old, I can turn their car seat facing forward." - This is incorrect as rear