Nokea
A multigravid client at 38 weeks' gestation, G4 P3, is 6 cm dilated with contractions every 3 minutes. The nurse observes meconium-stained amniotic fluid after spontaneous rupture of membranes. What is the priority nursing action?
- A. Prepare for immediate cesarean delivery.
- B. Assess the fetal heart rate pattern.
- C. Suction the client's oropharynx.
- D. Document the fluid characteristics.
Correct Answer: B
Rationale: Meconium-stained fluid raises the risk of fetal distress. Assessing the fetal heart rate pattern immediately ensures the fetus is tolerating labor. Cesarean delivery is not automatic, suctioning is irrelevant, and documentation follows assessment.
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A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?
- A. Withdrawal symptoms usually do not occur until 7 days postpartum.
- B. Large-for-gestational-age size is common with this condition.
- C. Facial deformities associated with FAS can be corrected by plastic surgery.
- D. Symptoms of withdrawal include tremors, sleeplessness, and seizures.
Correct Answer: D
Rationale: Symptoms of withdrawal in FAS include tremors, sleeplessness, and seizures due to neurological effects of alcohol exposure.
While assisting a primiparous client with her first breast-feeding session, which of the following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth and grasp the nipple?
- A. Pull down gently on the neonate's chin and insert the nipple.
- B. Squeeze both of the neonate's cheeks simultaneously.
- C. Place the nipple into the neonate's mouth on top of the tongue.
- D. Brush the neonate's lips lightly with the nipple.
Correct Answer: D
Rationale: Brushing the neonate's lips with the nipple stimulates the rooting reflex, encouraging the mouth to open.
The nurse is working with four clients on the obstetrical unit. Which client will be the highest priority for a cesarean section?
- A. Client at 40 weeks' gestation whose fetus weighs 8 lb by ultrasound estimate.
- B. Client at 37 weeks' gestation with fetus in ROP position.
- C. Client at 32 weeks' gestation with fetus in breech position.
- D. Client at 38 weeks' gestation with active herpes lesions.
Correct Answer: D
Rationale: Active herpes lesions necessitate a cesarean delivery to prevent neonatal transmission.
A 6-lb, 8-oz neonate was delivered vaginally at 38 weeks' gestation. At 5 minutes of life, the neonate has the following signs: heart rate 110 , intermittent grunting with respiratory rate of 70 , flaccid tone, no response to stimulus, overall pale white in color. The Apgar score is:
- A. 2
- B. 3
- C. 4
- D. 6
Correct Answer: B
Rationale: Heart rate 110 (2 points), respiratory effort with grunting (1 point), flaccid tone (0 points), no response to stimulus (0 points), pale white color (0 points). Total Apgar score = 3.
A client asks about the effectiveness of natural family planning methods. Which of the following responses by the nurse is most accurate?
- A. Natural family planning is as effective as oral contraceptives when used correctly.
- B. The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods.
- C. Natural family planning is less effective than barrier methods like condoms.
- D. Natural family planning requires no special equipment or cost.
Correct Answer: B
Rationale: The effectiveness of natural family planning depends on consistent monitoring and abstinence during fertile periods. It is less effective than oral contraceptives or barrier methods due to variability in ovulation and user adherence.