Nokea
A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member?
- A. Allow the sibling to hold the newborn during a bath.
- B. Make sure the sibling kisses the newborn each night.
- C. Obtain a gift from the newborn to present to the sibling.
- D. Switch the sibling's room with the nursery.
Correct Answer: C
Rationale: The correct answer is C: Obtain a gift from the newborn to present to the sibling. This suggestion helps foster acceptance and bonding between the siblings by creating a positive association and sense of reciprocity. It allows the 7-year-old to feel included and appreciated in the new family dynamic.
Explanation of why the other choices are incorrect:
A: Allowing the sibling to hold the newborn during a bath may not be safe or appropriate, and could potentially lead to accidents or discomfort for the newborn.
B: Forcing physical affection like kissing may not be well-received by the sibling and could create negative feelings towards the newborn.
D: Switching the sibling's room with the nursery could disrupt the sibling's sense of stability and security, potentially causing confusion and anxiety.
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A client who is at 22 weeks of gestation reports concern about the blotchy hyperpigmentation on her forehead. Which of the following actions should the nurse take?
- A. Tell the client to follow up with a dermatologist.
- B. Explain to the client this is an expected occurrence.
- C. Instruct the client to increase her intake of vitamin D.
- D. Inform the client she might have an allergy to her skin care products.
Correct Answer: B
Rationale: The correct answer is B. The blotchy hyperpigmentation on the client's forehead is likely melasma, a common occurrence during pregnancy. This is due to hormonal changes causing increased melanin production. The nurse should educate the client that this is an expected occurrence during pregnancy and reassure her that it is usually temporary and will fade postpartum.
Choice A (Tell the client to follow up with a dermatologist) is incorrect because dermatological consultation is not typically necessary for melasma during pregnancy.
Choice C (Instruct the client to increase her intake of vitamin D) is incorrect because vitamin D deficiency is not typically associated with blotchy hyperpigmentation on the forehead during pregnancy.
Choice D (Inform the client she might have an allergy to her skin care products) is incorrect because melasma is not caused by allergies to skincare products.
A client who is 2 hours postpartum is in the taking-hold phase. Which intervention should the nurse plan to implement during this phase of postpartum behavioral adjustment?
- A. Discuss contraceptive options with the client and her partner.
- B. Repeat information to ensure client understanding.
- C. Listen to the client and her partner as they reflect upon the birth experience.
- D. Demonstrate to the client how to perform a newborn bath.
Correct Answer: D
Rationale: The correct answer is D because during the taking-hold phase, the client is focused on learning and mastering new skills related to caring for the newborn. Demonstrating how to perform a newborn bath aligns with this phase as it helps the client gain confidence and competence in newborn care. Discussing contraceptive options (choice A) is more appropriate during the let-go phase. Repeating information (choice B) may be necessary but is not the priority during the taking-hold phase. Listening to the client and her partner reflect on the birth experience (choice C) is important for emotional support but not specifically related to the behavioral adjustments in the taking-hold phase.
A client is in labor, and a nurse observes late decelerations on the electronic fetal monitor. What should the nurse identify as the first action that the registered nurse should take?
- A. Assist the client into the left-lateral position
- B. Apply a fetal scalp electrode
- C. Insert an IV catheter
- D. Perform a vaginal exam
Correct Answer: A
Rationale: The correct answer is A: Assist the client into the left-lateral position. This is the first action because it helps improve placental perfusion, which can alleviate late decelerations associated with uteroplacental insufficiency. The left-lateral position promotes optimal blood flow and oxygenation to the placenta by reducing pressure on the vena cava and improving maternal perfusion. This position can potentially prevent further fetal distress.
Summary of other choices:
B: Applying a fetal scalp electrode is not the first action for addressing late decelerations. It may be considered later for more precise monitoring.
C: Inserting an IV catheter is important but not the priority when late decelerations are observed.
D: Performing a vaginal exam is not indicated as the first action for addressing late decelerations and could potentially increase the risk of infection.
A client who is pregnant is scheduled for a contraction stress test (CST). Which of the following findings are indications for this procedure? (Select all that apply)
- A. Decreased fetal movement
- B. Intrauterine growth restriction (IUGR)
- C. Postmaturity
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D, All of the Above.
1. Decreased fetal movement indicates fetal distress, necessitating CST.
2. IUGR implies potential placental insufficiency, requiring CST evaluation.
3. Postmaturity increases risk of placental insufficiency, warranting CST.
Other choices are incorrect as they do not directly indicate the need for CST in a pregnant client.
A client at 40 weeks of gestation is experiencing contractions every 3 to 5 minutes, becoming stronger. A vaginal exam by the registered nurse reveals the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client requests pain medication. Which of the following actions should the nurse prepare to take? (Select all that apply)
- A. Provide ice chips.
- B. Insert an indwelling urinary catheter.
- C. Administer opioid analgesic medication.
- D. Provide ice chips.
Correct Answer: C
Rationale: The correct action is to administer opioid analgesic medication (Choice C). At 40 weeks gestation with contractions every 3-5 minutes, 3 cm dilated, 80% effaced, and -1 station, the client is in active labor. Pain medication is appropriate to manage discomfort during labor. Opioid analgesics can help reduce pain intensity while still allowing the client to remain alert and participate in labor. Ice chips (Choice A and D) are not directly related to pain management in labor. Inserting a urinary catheter (Choice B) is not indicated unless there are specific concerns about bladder distention.