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Which newborn is at highest risk of a skin infection? of the FHR?
- A. Infant born at 36 weeks who is being bottle fed
- B. Right lower abdomen
- C. Infant whose umbilical cord fell off on day 8 of life
- D. Near client umbilicus
Correct Answer: C
Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.
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The nurse is educating a pregnant client about group B streptococcus (GBS) testing. When is this typically performed?
- A. At the first prenatal visit.
- B. Between 35–37 weeks' gestation.
- C. During the second trimester.
- D. After 40 weeks' gestation.
Correct Answer: B
Rationale: GBS testing is typically performed between 35–37 weeks to identify and manage infection risks during delivery.
A pregnant client asks about the purpose of an ultrasound at 20 weeks' gestation. What is the best response?
- A. To confirm pregnancy viability.
- B. To check for genetic abnormalities.
- C. To assess fetal anatomy and growth.
- D. To determine the sex of the baby.
Correct Answer: C
Rationale: The 20-week ultrasound is primarily for assessing fetal anatomy, growth, and development.
A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
A client in labor receiving an epidural reports feeling lightheaded and nauseous. What is the nurse's priority intervention?
- A. Administer antiemetics as prescribed.
- B. Check maternal blood pressure.
- C. Increase the oxytocin infusion rate.
- D. Encourage the client to lie on her back.
Correct Answer: B
Rationale: Lightheadedness and nausea can be signs of hypotension, a common side effect of epidural anesthesia.
The nurse is educating a client about exercises during pregnancy. What activity should be avoided?
- A. Swimming.
- B. Walking.
- C. Contact sports.
- D. Prenatal yoga.
Correct Answer: C
Rationale: Contact sports pose a risk of trauma to the mother and fetus and should be avoided during pregnancy.