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A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?
- A. Ineffective airway clearance related to postterm gestational age.
- B. Hyperthermia related to large size and use of a radiant warmer.
- C. Decreased cardiac output related to difficult delivery.
- D. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores.
Correct Answer: D
Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.
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After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
- A. 6 months.
- B. 12 months.
- C. 18 months.
- D. 24 months.
Correct Answer: B
Rationale: Waiting 12 months allows for monitoring for choriocarcinoma.
A multigravid client is in active labor with twins at 38 weeks' gestation. The nurse should monitor the client closely for symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Urinary tract infection.
- C. Chorioamnionitis.
- D. Precipitous delivery.
Correct Answer: D
Rationale: Twin pregnancies increase the risk of precipitous delivery due to uterine overdistension, which can lead to rapid labor. Hypertension, infections, or chorioamnionitis are possible but less specific to twins.
Before surgery to remove an ectopic pregnancy and the fallopian tube, which of the following would alert the nurse to the possibility of tubal rupture?
- A. Amount of vaginal bleeding and discharge.
- B. Falling hematocrit and hemoglobin levels.
- C. Slow, bounding pulse rate of 80 bpm.
- D. Marked abdominal edema.
Correct Answer: B
Rationale: Falling hematocrit and hemoglobin levels indicate internal bleeding.
A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?
- A. Use an appropriate nipple and bottle set.
- B. Encourage the mother to breast-feed.
- C. Assess daily weights and wet diapers to monitor intake.
- D. Allow unlimited length of time for each feeding.
Correct Answer: A
Rationale: Using an appropriate nipple and bottle set designed for cleft palate infants minimizes aspiration risk during feedings.
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.