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A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
- A. Preterm newborns have a smaller body surface area than normal newborns.
- B. The added brown fat layer in a preterm newborn reduces his ability to generate heat.
- C. Preterm newborns lack adequate temperature control mechanisms.
- D. The heat in the incubator rapidly dries the sweat of preterm newborns.
Correct Answer: C
Rationale: The correct answer is C because preterm newborns lack adequate temperature control mechanisms. Preterm infants have underdeveloped regulatory systems, making them vulnerable to heat loss or overheating. Maintaining a neutral thermal environment in an incubator helps prevent fluctuations in body temperature.
Choice A is incorrect because surface area alone does not explain the need for a neutral thermal environment. Choice B is incorrect as brown fat actually helps generate heat in newborns. Choice D is incorrect as drying sweat is not the primary reason for using an incubator in preterm newborns.
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A client is scheduled for a maternal serum alpha-fetoprotein test at 15 weeks of gestation. The client asks the nurse about the purpose of this test. What explanation should the nurse provide?
- A. This test screens for neural tube defects and other developmental abnormalities in the fetus.
- B. It assesses various markers of fetal well-being.
- C. This test identifies an Rh incompatibility between the mother and fetus.
- D. It is a screening test for spinal defects in the fetus.
Correct Answer: A
Rationale: The correct answer is A because the maternal serum alpha-fetoprotein test is specifically used to screen for neural tube defects and other developmental abnormalities in the fetus. Alpha-fetoprotein levels in the mother's blood can indicate the presence of such abnormalities. This test is typically done around 15-20 weeks of gestation.
Choice B is incorrect because the maternal serum alpha-fetoprotein test is not used to assess various markers of fetal well-being. Choice C is incorrect because it does not identify Rh incompatibility, which is typically detected through other tests. Choice D is incorrect because the test is not primarily for spinal defects, but rather for neural tube defects and other developmental abnormalities.
A client in labor is having contractions 4 minutes apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing?
- A. Contractions that last for 60 seconds each with a 4-minute rest between contractions
- B. A contraction that lasts 4 minutes followed by a period of relaxation
- C. Contractions that last for 60 seconds each with a 3-minute rest between contractions
- D. Contractions that last 45 seconds each with a 3-minute rest between contractions
Correct Answer: C
Rationale: The correct answer is C: Contractions that last for 60 seconds each with a 3-minute rest between contractions. In active labor, contractions typically last around 60 seconds each and occur about 2-5 minutes apart. With contractions 4 minutes apart, a 3-minute rest between contractions aligns with the expected pattern. Choice A is incorrect as the rest between contractions is too long. Choice B is incorrect as a contraction lasting 4 minutes is not typical in labor. Choice D is incorrect as the duration of contractions is shorter than expected in active labor. Therefore, Choice C is the most fitting pattern based on the frequency and duration of contractions during labor.
A nurse in a prenatal clinic overhears a newly licensed nurse discussing conception with a client. Which of the following statements by the newly licensed nurse requires intervention by the nurse?
- A. Fertilization takes place in the outer third of the fallopian tube.
- B. Implantation occurs between 6 to 10 days after conception.
- C. Sperm remain viable in the woman's reproductive tract for 2 to 3 days.
- D. Bleeding or spotting can accompany implantation.
Correct Answer: B
Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention.
A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct.
C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate.
D: Bleeding or spotting can indeed accompany implantation, making this statement correct.
In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.
A client who is at 39 weeks of gestation and is in active labor has fetal heart tones located above the umbilicus at midline. The fetus is likely in which of the following positions?
- A. Cephalic
- B. Transverse
- C. Posterior
- D. Frank breech
Correct Answer: D
Rationale: The correct answer is D: Frank breech. In a frank breech position, the buttocks of the fetus are presenting first, which is why the fetal heart tones can be heard above the umbilicus at midline. In this position, the feet are near the head, causing the buttocks to be the presenting part. Choices A, B, and C are incorrect because in a cephalic position, the head would be presenting, in a transverse position, the baby would be lying sideways, and in a posterior position, the baby's back would be against the mother's back.
A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct Answer: D
Rationale: The correct answer is D: Assist the client to turn onto her side. This intervention is essential to improve blood flow to the placenta and fetus, thus helping to increase blood pressure and prevent hypotension. Turning the client onto her side can help relieve pressure on the vena cava, allowing for better circulation.
A: Preparing for a cesarean birth is not indicated based solely on the client's blood pressure reading.
B: Assisting the client to an upright position may worsen hypotension as it can further decrease blood flow to the placenta.
C: Preparing for an immediate vaginal delivery is not necessary solely based on the client's blood pressure reading.