Nokea
A client at 12 weeks' gestation reports mild cramping and spotting. What is the nurse's priority intervention?
- A. Reassure the client that this is normal.
- B. Encourage the client to hydrate.
- C. Advise the client to avoid heavy lifting.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Spotting and cramping in early pregnancy could indicate a threatened miscarriage, requiring immediate evaluation.
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A parent asks the nurse what makes the opening between the baby's atrium close at birth? The nurse's response is that cardiovascular changes that cause to foramen ovale to close at birth are the direct result of:
- A. Increased pressure in the L atrium (with the increase in the blood flow to the L atrium from the lungs, the pressure is
- C. Increased pressure in the R atrium
- D. Changes in the hepatic blood flow
Correct Answer: C
Rationale: The foramen ovale is a normal fetal structure that allows blood to bypass the lungs by shunting blood from the right atrium to the left atrium. This is essential during fetal development since the lungs are not functioning until birth. After birth, when the baby takes its first breaths and the lungs start working, the pressure in the left atrium increases due to the increased blood flow from the pulmonary circulation. This increased pressure in the left atrium causes the foramen ovale to close, preventing blood from flowing from the right atrium to the left atrium. Therefore, the closure of the foramen ovale is a result of the increased pressure in the left atrium rather than any other cardiovascular changes.
A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.
The nurse is caring for a postpartum client who is
- A. Maternal hyperglycemia 1 day postcesarean birth. What assessment data
- B. FHR, early decelerations would indicate infection? Select all that apply.
- C. FHR, late decelerations
- D. Increased pulse
Correct Answer: A
Rationale: Maternal hyperglycemia 1 day post-cesarean birth can indicate infection. Hyperglycemia can impair immune function and make the body more susceptible to infections.
What method of heat loss may occur if a newborn is placed on a cold scale or touch with cold hands:
- A. Conduction (occurs when the infant comes in contact with cold objects)
Correct Answer: A
Rationale: Conduction is the transfer of heat between objects that are in direct contact with each other. In the scenario where a newborn is placed on a cold scale or touched with cold hands, heat loss occurs through conduction. The cold temperature of the scale or hands will draw heat away from the infant's body, leading to a drop in body temperature. It is essential to ensure that newborns are not exposed to cold surfaces or objects for prolonged periods to prevent heat loss through conduction and maintain their body temperature within a safe range.
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.