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.
You may also like to solve these questions
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 is being discharged after childbirth. At 4 weeks postpartum, the client should contact the provider for which of the following client findings?
- A. Scant, non-odorous white vaginal discharge
- B. Uterine cramping during breastfeeding
- C. Sore nipple with cracks and fissures
- D. Decreased response with sexual activity
Correct Answer: C
Rationale: The correct answer is C: Sore nipple with cracks and fissures. This is indicative of possible breastfeeding issues like improper latch or infection, requiring prompt intervention to prevent complications. Scant, non-odorous white vaginal discharge (A) is normal postpartum lochia. Uterine cramping during breastfeeding (B) is common due to oxytocin release. Decreased response with sexual activity (D) is a common postpartum concern but not an urgent issue at 4 weeks. Addressing sore nipples promptly is crucial for successful breastfeeding and maternal well-being.
When assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?
- A. Oxygen saturation
- B. Body temperature
- C. Serum bilirubin
- D. Heart rate
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation. Monitoring oxygen saturation is crucial in evaluating the newborn's respiratory status post-surfactant administration. It helps assess the effectiveness of surfactant therapy in improving oxygenation. Body temperature and serum bilirubin are not directly related to assessing respiratory distress syndrome. Heart rate may be affected by various factors and may not provide specific information on respiratory status.
A client has postpartum psychosis. Which of the following actions is the nurse's priority?
- A. Reinforce the importance of taking antipsychotics as prescribed
- B. Ask the client if they have thoughts of harming themselves or their infant
- C. Monitor the infant for signs of failure to thrive
- D. Check the client's medical record for a history of bipolar disorder
Correct Answer: B
Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.
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.