Nokea
A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?
- A. Heart rate 168/min
- B. Respiratory rate 18/min
- C. Tremors
- D. Fine crackles
Correct Answer: B
Rationale: Correct Answer: B (Respiratory rate 18/min)
Rationale: A normal respiratory rate for a newborn is 30-60 breaths/min. A rate of 18/min is below the normal range, indicating potential respiratory distress requiring immediate intervention to ensure adequate oxygenation.
Summary of other choices:
A: Heart rate 168/min - Normal range for a newborn is 120-160/min.
C: Tremors - Common in newborns due to immature nervous system, usually self-resolving.
D: Fine crackles - May be present due to residual amniotic fluid and typically resolve without intervention.
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A client who is at 12 weeks of gestation is reviewing a new prescription of ferrous sulfate. Which of the following statements by the client indicates understanding of the teaching?
- A. I will take this pill with my breakfast.
- B. I will take this medication with a glass of milk.
- C. I plan to drink more orange juice while taking this pill.
- D. I plan to add more calcium-rich foods to my diet while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: "I plan to drink more orange juice while taking this pill." Orange juice is rich in vitamin C, which enhances the absorption of iron from ferrous sulfate, helping to combat iron deficiency anemia during pregnancy. Taking the pill with a vitamin C source is important for optimal absorption.
A: Taking the pill with breakfast may not provide enough vitamin C for optimal absorption.
B: Milk may inhibit iron absorption due to its calcium content, so it is not ideal to take with ferrous sulfate.
D: While increasing calcium-rich foods is important during pregnancy, it is not directly related to enhancing iron absorption from ferrous sulfate.
A healthcare professional is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the professional use to help minimize the pain of the procedure for the newborn?
- A. Apply a cool pack to the heel for 10 minutes prior to the puncture.
- B. Request a prescription for IM analgesic.
- C. Use a manual lancet to pierce the skin.
- D. Place the newborn skin-to-skin on the mother's chest.
Correct Answer: D
Rationale: The correct answer is D: Place the newborn skin-to-skin on the mother's chest. This technique promotes bonding, warmth, and comfort, which can help minimize the newborn's pain perception during the procedure. Skin-to-skin contact releases oxytocin, which has analgesic effects. It also provides emotional support and reduces stress for both the newborn and the mother.
A, applying a cool pack, may cause vasoconstriction and increase pain perception. B, requesting an IM analgesic, is not typically necessary for a routine heel stick and may have potential adverse effects. C, using a manual lancet, does not address the emotional and psychological aspects of pain perception in newborns.
A healthcare provider is assisting with the care for a client who reports manifestations of preterm labor. Which of the following findings are risk factors for this condition? (Select all that apply)
- A. Urinary tract infection
- B. Multifetal pregnancy
- C. Oligohydramnios
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D because all of the choices are risk factors for preterm labor.
A: Urinary tract infection can lead to inflammation and contractions.
B: Multifetal pregnancy puts more stress on the uterus, increasing the risk.
C: Oligohydramnios is associated with a higher risk of preterm labor due to decreased amniotic fluid levels.
In summary, all the choices contribute to the increased likelihood of preterm labor.
A healthcare provider is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the provider expect? (Select all that apply)
- A. Chadwick's sign
- B. Goodell's sign
- C. Ballottement
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D because all three signs (Chadwick's sign, Goodell's sign, and Ballottement) are probable signs of pregnancy. Chadwick's sign refers to bluish discoloration of the cervix, Goodell's sign is softening of the cervix, and Ballottement is a palpable rebound of the fetus against the examiner's fingers. These signs are indicative of pregnancy and are commonly observed in pregnant individuals. Therefore, the provider should expect to see all these findings in a pregnant client. The other choices (A, B, and C) are incorrect because each of these signs individually is a probable sign of pregnancy, and the question asks for all the expected findings, not just one or two of them.
A client is to receive oxytocin to augment labor. Which finding contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations
- B. Moderate variability of the FHR
- C. Cessation of uterine dilation
- D. Prolonged active phase of labor
Correct Answer: A
Rationale: The correct answer is A. Late decelerations indicate fetal distress, suggesting compromised oxygenation. Starting oxytocin can further stress the fetus, worsening decelerations. Report to prevent harm. B is incorrect as moderate variability is a reassuring sign of fetal well-being. C is incorrect as cessation of uterine dilation may indicate uterine hyperstimulation, not fetal distress. D is incorrect as prolonged active labor phase alone doesn't necessarily contraindicate oxytocin, but it may require monitoring.