Nokea
A nurse is receiving laboratory results for a term newborn who is 24 hr. old. Which of the following results require intervention by the nurse?
- A. WBC count 10,000/mm3
- B. Platelets 180,000/mm3
- C. Hemoglobin 20g/dL
- D. Glucose 20 mg/dL
Correct Answer: D
Rationale: The correct answer is D because a glucose level of 20 mg/dL in a term newborn is significantly low and requires immediate intervention by the nurse. Low glucose levels can lead to hypoglycemia, which can be harmful to the newborn's brain development and overall health. A WBC count of 10,000/mm3 is within normal range for a newborn. Platelets of 180,000/mm3 and hemoglobin of 20g/dL are also within normal limits for a term newborn and do not require intervention.
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A postpartum client calls the pediatric clinic to report that her 4-day old female newborn has a spot of blood on her diaper. Which of the following statements made by the nurse is most appropriate?
- A. Your newborn may have a urinary infection, continue to breastfeed frequently
- B. Your newborn has jaundice so it may need phototherapy
- C. This is a normal finding due to withdrawal of maternal hormones
- D. Your baby has an immature immune system, continue to breastfeed frequently
Correct Answer: C
Rationale: The correct answer is C because the spot of blood on the diaper of a 4-day old female newborn is a normal finding due to the withdrawal of maternal hormones. During pregnancy, the baby is exposed to maternal hormones, and after birth, the sudden decrease in these hormones can cause a temporary withdrawal bleeding. This is known as pseudomenstruation and is common in newborn girls. It is important for the nurse to reassure the mother that this is a normal and harmless occurrence.
Choice A is incorrect because urinary infection is not typically the cause of blood on the diaper in a newborn. Choice B is incorrect because jaundice does not typically present with blood in the diaper. Choice D is incorrect because while breastfeeding is important for the baby's immune system, it is not directly related to the presence of blood on the diaper in this case.
A pregnant patient who abuses cocaine admits to exchanging sex for her drug habit. This behavior puts her at a greater risk for
- A. postmature birth.
- B. sexually transmitted diseases.
- C. hypotension and vasodilation.
- D. depression of the central nervous system.
Correct Answer: B
Rationale: The correct answer is B: sexually transmitted diseases. Exchanging sex for drugs increases the risk of acquiring STDs due to engaging in unprotected sex with multiple partners. This behavior exposes the patient to infections such as HIV, syphilis, gonorrhea, and others. STDs can have serious consequences for both the pregnant patient and the fetus, including transmission of infections during childbirth or pregnancy complications.
A: postmature birth is incorrect as it is not directly related to the behavior described.
C: hypotension and vasodilation are potential effects of cocaine abuse, but not directly related to the increased risk of STDs in this scenario.
D: depression of the central nervous system is a potential effect of cocaine abuse but is not the primary concern in this situation.
A client at 12 weeks' gestation asks about the purpose of nuchal translucency testing. What is the nurse's best response?
- A. It screens for fetal anemia.
- B. It detects neural tube defects.
- C. It screens for chromosomal abnormalities.
- D. It confirms gestational age.
Correct Answer: C
Rationale: The correct answer is C because nuchal translucency testing is primarily used to screen for chromosomal abnormalities, such as Down syndrome, in the fetus. This test measures the thickness of the fluid-filled space at the back of the baby's neck. It is typically done between 11 and 14 weeks of pregnancy. This testing helps to assess the risk of genetic conditions in the fetus. Option A is incorrect because nuchal translucency testing does not screen for fetal anemia. Option B is incorrect because it does not detect neural tube defects. Option D is incorrect because it does not confirm gestational age.
What is a common preconception risk factor that can impact pregnancy outcomes?
- A. lack of exercise prior to pregnancy
- B. chronic caffeine intake
- C. high fat diet
- D. lack of immunizations
Correct Answer: D
Rationale: The correct answer is D, lack of immunizations. Immunizations protect pregnant individuals from serious infections that can harm both the mother and the baby. Infections like influenza and pertussis can lead to complications such as preterm birth, low birth weight, and even fetal death. Ensuring that pregnant individuals are up to date on their immunizations helps safeguard their health and the health of their unborn child.
Choice A, lack of exercise, may impact pregnancy outcomes, but it is not as significant as the risk posed by lack of immunizations in terms of preventing serious complications. Chronic caffeine intake (Choice B) and high-fat diet (Choice C) can also have negative effects on pregnancy outcomes, but they are not as directly linked to potential harm for the mother and baby as the lack of immunizations.
A nurse is completing a health history for a client who is at 6-week gestation. The client informs the nurse that she smokes one park of cigarettes per day. The nurse should advise the client that smoking places the client9s newborn at risk for what complication?
- A. Hearing loss
- B. Intrauterine growth restriction
- C. Type 1 diabetes mellitus
- D. Congenital heart defects
Correct Answer: B
Rationale: The correct answer is B: Intrauterine growth restriction (IUGR). Smoking during pregnancy can restrict blood flow to the fetus, leading to inadequate oxygen and nutrients, resulting in IUGR. This can lead to low birth weight and potential health complications for the newborn. Hearing loss (A) is not directly associated with smoking during pregnancy. Type 1 diabetes mellitus (C) is an autoimmune condition not caused by maternal smoking. Congenital heart defects (D) can be a risk with smoking during pregnancy, but the most direct risk is IUGR.