Nokea
A client who is at 42 weeks gestation and in labor asks the nurse what to expect because the baby is postmature. Which of the following statements should the nurse make?
- A. Your baby will have excess baby fat.
- B. Your baby will have flat areola without breast buds.
- C. Your baby's heels will easily move to his ears.
- D. Your baby's skin will have a leathery appearance.
Correct Answer: D
Rationale: The correct answer is D because a baby who is postmature may have dry, cracked, and peeling skin, leading to a leathery appearance due to prolonged exposure to amniotic fluid. This occurs as the protective vernix caseosa diminishes over time. Choice A is incorrect because excess baby fat is not a typical characteristic of postmaturity. Choice B is incorrect as flat areola without breast buds is not a common feature of postmaturity. Choice C is incorrect as the ability to easily move heels to ears is a sign of flexibility and does not specifically relate to postmaturity.
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A client in the delivery room just delivered a newborn, and the nurse is planning to promote parent-infant bonding. What should the nurse prioritize?
- A. Encourage the parents to touch and explore the newborn's features
- B. Limit noise and interruptions in the delivery room
- C. Place the newborn at the client's breast
- D. Position the newborn skin-to-skin on the client's chest
Correct Answer: D
Rationale: The correct answer is D: Position the newborn skin-to-skin on the client's chest. This promotes bonding through touch, warmth, and smell, stimulating the release of oxytocin in both the parent and the infant. Skin-to-skin contact enhances attachment, regulates the newborn's temperature and breathing, and supports breastfeeding initiation.
A: Encouraging parents to touch and explore the newborn's features is important but not as crucial as immediate skin-to-skin contact for bonding and physiological benefits.
B: Limiting noise and interruptions can create a calm environment but does not directly promote bonding like skin-to-skin contact.
C: Placing the newborn at the client's breast is beneficial for breastfeeding initiation but may not provide the same level of closeness and comfort as skin-to-skin contact.
A newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight should be classified as which of the following?
- A. Low birth weight
- B. Appropriate for gestational age
- C. Small for gestational age
- D. Large for gestational age
Correct Answer: B
Rationale: The correct answer is B: Appropriate for gestational age. A newborn is considered appropriate for gestational age when their weight falls within the 10th to 90th percentiles for their gestational age. In this case, the newborn is in the 60th percentile for weight, indicating that the weight is appropriate for the gestational age of 38 weeks.
Choice A: Low birth weight is incorrect because a newborn is classified as low birth weight when their weight is below 2,500 g regardless of gestational age.
Choice C: Small for gestational age is incorrect because a newborn is classified as small for gestational age when their weight is below the 10th percentile for their gestational age.
Choice D: Large for gestational age is incorrect because a newborn is classified as large for gestational age when their weight is above the 90th percentile for their gestational age.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On data collection, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being?
- A. Evidence of a possible vaginal hematoma
- B. An indication of a cervical or perineal laceration
- C. A normal postpartum discharge of lochia
- D. Abnormally excessive lochia rubra flow
Correct Answer: C
Rationale: The correct answer is C: A normal postpartum discharge of lochia. This finding indicates a normal postpartum process. Lochia is the vaginal discharge after childbirth consisting of blood, mucus, and uterine tissue. The gush of dark red blood followed by cessation is typical of lochia rubra, the initial stage of postpartum bleeding. The firm, midline, and well-positioned uterus indicates proper involution. Choices A and B are incorrect as the firm uterus rules out hematoma or laceration. Choice D is incorrect as the amount of bleeding described is within the normal range for postpartum lochia.
A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?
- A. Peanut butter
- B. Potatoes
- C. Apple juice
- D. Broccoli
Correct Answer: A
Rationale: The correct answer is A: Peanut butter. Phenylketonuria (PKU) is a metabolic disorder where the body can't process phenylalanine found in protein foods. Peanut butter is high in protein and contains phenylalanine, so it should be eliminated from the client's diet. Potatoes, apple juice, and broccoli are low in protein and do not contain high levels of phenylalanine, so they do not need to be eliminated. It is crucial for the client to avoid foods high in phenylalanine to prevent the buildup of toxic levels in the body, which can lead to serious health issues.
A client who is 2 days postpartum has a saturated perineal pad with bright red lochia containing small clots. What should the nurse document in the client's medical record?
- A. Moderate lochia rubra
- B. Excessive lochia serosa
- C. Light lochia rubra
- D. Scant lochia serosa
Correct Answer: A
Rationale: The correct answer is A: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.