Nokea
A multigravid client in active labor at 39 weeks' gestation has a history of smoking one to two packs of cigarettes daily. For which of the following should the nurse be alert when assessing the client's neonate?
- A. Hyperirritability.
- B. Hyperbilirubinemia.
- C. Low birth weight.
- D. Hypocalcemia.
Correct Answer: C
Rationale: Maternal smoking is strongly associated with low birth weight due to placental insufficiency and reduced fetal growth. Hyperirritability, hyperbilirubinemia, and hypocalcemia are less directly linked.
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A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and delivery unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client delivers a healthy neonate vaginally with a midline episiotomy. Which of the following nursing diagnoses should the nurse identify as the priority for the client?
- A. Activity intolerance related to difficult labor process.
- B. Sleep deprivation related to prolonged labor.
- C. Situational low self-esteem related to lengthy labor process.
- D. Risk for infection related to birth trauma and prolonged ruptured membranes.
Correct Answer: D
Rationale: Prolonged rupture of membranes (>24 hours) and episiotomy increase infection risk, making this the priority post-delivery. Activity intolerance, sleep deprivation, and self-esteem are less urgent.
A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following?
- A. An immature cardiac sphincter.
- B. A defect in the gastrointestinal system.
- C. Burping the infant too frequently.
- D. Moving the infant during the feeding.
Correct Answer: A
Rationale: An immature cardiac sphincter in newborns can cause regurgitation of formula.
The physician orders betamethasone (Celestone) for a 34-year-old multigravid client at 32 weeks' gestation who is experiencing preterm labor. Previously, the client has experienced one infant death due to preterm birth at 28 weeks' gestation. The nurse explains that this drug is given for which of the following reasons?
- A. To enhance fetal lung maturity.
- B. To counter the effects of tocolytic therapy.
- C. To treat chorioamnionitis.
- D. To decrease neonatal production of surfactant.
Correct Answer: A
Rationale: Betamethasone enhances fetal lung maturity.
A client asks about the risks of long-term oral contraceptive use. Which of the following would the nurse include?
- A. Increased risk of blood clots.
- B. Permanent weight loss.
- C. Elimination of ovarian cancer risk.
- D. Guaranteed regular menstrual cycles.
Correct Answer: A
Rationale: Long-term use of oral contraceptives may increase the risk of blood clots, especially in at-risk populations. It may reduce ovarian cancer risk, does not cause permanent weight loss, and does not guarantee regular cycles.
The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unlicensed nursing personnel?
- A. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin.
- B. A G4 P4 who is breast-feeding an 8 lb infant without difficulty.
- C. A G3 P3 postpartum client who is receiving Magnesium Sulfate and whose infant has a respiratory rate of 20.
- D. A G2 P2 who delivered vaginally 2 days ago with an infant having low blood glucose levels the first 24 hours post delivery.
Correct Answer: B
Rationale: The G4 P4 client with stable breastfeeding is appropriate for UAP delegation, as no complex medical needs are present.