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A client at 11 weeks of gestation reports slight occasional vaginal bleeding over the past 2 weeks. After an examination, the provider informs the client that the fetus has died, and the placenta, fetus, and tissues remain in the uterus. How should the nurse document these findings?
- A. Incomplete miscarriage
- B. Missed miscarriage
- C. Inevitable miscarriage
- D. Complete miscarriage
Correct Answer: B
Rationale: The correct answer is B: Missed miscarriage. At 11 weeks gestation, the fetus has died but has not been expelled from the uterus. This is known as a missed miscarriage. The other choices are incorrect because:
A: Incomplete miscarriage involves partial expulsion of the products of conception.
C: Inevitable miscarriage indicates that the miscarriage is in progress and cannot be stopped.
D: Complete miscarriage refers to the complete expulsion of all products of conception from the uterus.
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During an assessment, a healthcare provider observes small pearly white nodules on the roof of a newborn's mouth. This finding is a characteristic of which of the following conditions?
- A. Mongolian spots
- B. Milia spots
- C. Erythema toxicum
- D. Epstein's pearls
Correct Answer: D
Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment.
A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth.
B: Milia spots are small, white, raised bumps on the skin, not found in the mouth.
C: Erythema toxicum is a common benign rash in newborns, not related to the mouth.
In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.
A caregiver is being taught about bottle feeding a newborn. Which of the following statements by the caregiver indicates a need for further instruction?
- A. I will keep the baby's head elevated while feeding.
- B. I will allow the baby to burp several times during each feeding.
- C. I will tilt the bottle to prevent air from entering as the baby sucks.
- D. My baby will have soft, formed yellow stools.
Correct Answer: C
Rationale: The correct answer is C. Tilt the bottle to prevent air from entering as the baby sucks is incorrect. It is important not to tilt the bottle as it can cause the baby to swallow air, leading to gas and discomfort. A: Keeping the baby's head elevated helps prevent choking. B: Allowing the baby to burp reduces gas and discomfort. D: Soft, formed yellow stools indicate a healthy digestive system. Thus, C is the only statement that may lead to issues and requires further instruction.
When reinforcing teaching with a group of new parents about proper techniques for bottle feeding, which of the following instructions should be provided?
- A. Burp the newborn at the end of the feeding
- B. Hold the newborn close in a supine position
- C. Keep the nipple full of formula throughout the feeding
- D. Refrigerate any unused formula
Correct Answer: C
Rationale: Rationale:
C is correct because keeping the nipple full of formula throughout the feeding helps prevent the baby from swallowing air, reducing the risk of gas and colic. A is incorrect because burping should be done mid-feeding. B is incorrect because newborns should be held in an upright position while feeding to prevent choking. D is incorrect because unused formula should be discarded within 1-2 hours, not refrigerated.
A client at 28 weeks of gestation received terbutaline. Which of the following findings should the nurse expect?
- A. Fetal heart rate 100/min
- B. Weakened uterine contractions
- C. Enhanced production of fetal lung surfactant
- D. Maternal blood glucose 63 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Weakened uterine contractions. Terbutaline is a tocolytic medication that inhibits uterine contractions. This helps prevent preterm labor. At 28 weeks of gestation, the nurse would expect terbutaline to weaken uterine contractions, rather than increase fetal heart rate (choice A), enhance fetal lung surfactant production (choice C), or lower maternal blood glucose levels (choice D). Weakening of uterine contractions is the expected therapeutic effect of terbutaline in this scenario to delay preterm labor.
A client who is breastfeeding and has mastitis is receiving teaching from the nurse. Which of the following responses should the nurse make?
- A. Limit the amount of time the infant nurses on each breast.
- B. Nurse the infant only on the unaffected breast until resolved.
- C. Completely empty each breast at each feeding or use a pump.
- D. Wear a tight-fitting bra until lactation has ceased.
Correct Answer: C
Rationale: The correct answer is C: Completely empty each breast at each feeding or use a pump. This is the correct response because it helps to ensure effective milk removal, which is crucial for treating mastitis. By fully emptying the breast, the nurse can prevent milk stasis and promote healing.
A: Limiting the time the infant nurses on each breast may lead to incomplete milk removal, worsening the condition.
B: Nursing only on the unaffected breast does not address the issue of milk stasis in the affected breast and may lead to further complications.
D: Wearing a tight-fitting bra can exacerbate mastitis by restricting milk flow and increasing discomfort.