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A newborn was delivered vaginally and experienced a tight nuchal cord. Which of the following clinical manifestations should the nurse expect to observe?
- A. Bruising over the buttocks
- B. Hard nodules on the roof of the mouth
- C. Petechiae over the head
- D. Bilateral periauricular papillomas
Correct Answer: C
Rationale: The correct answer is C: Petechiae over the head. This is because tight nuchal cord can cause pressure on the baby's head during delivery, leading to tiny red or purple spots called petechiae due to capillary rupture. Bruising over the buttocks (A) is more common in breech deliveries, hard nodules on the roof of the mouth (B) could indicate Epstein pearls which are benign and common in newborns, and bilateral periauricular papillomas (D) are not related to nuchal cord compression.
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A client is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The client is in which of the following phases of labor?
- A. Active
- B. Transition
- C. Latent
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Transition. Transition phase occurs when the cervix is dilated from 8 to 10 cm. This phase is characterized by intense contractions close together, increased rectal pressure, and emotional changes. The client in this scenario has contractions 2 to 3 minutes apart, lasting 80 to 90 seconds, and the cervix is dilated to 9 cm. This aligns with the characteristics of the transition phase.
Summary:
A: Active phase occurs when the cervix is dilated from 4 to 7 cm.
C: Latent phase occurs when the cervix is dilated from 0 to 3 cm.
D: Descent phase is not a recognized phase of labor.
A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the following treatment modalities should the nurse anticipate?
- A. Epidural analgesia
- B. Naloxone hydrochloride
- C. Attention-focusing
- D. Pudendal nerve block
Correct Answer: C
Rationale: The correct answer is C: Attention-focusing. At 40 weeks gestation with a platelet count of 75,000/mm3, epidural analgesia is contraindicated due to the risk of epidural hematoma. Naloxone hydrochloride is an opioid antagonist used for opioid overdose, not for labor pain relief. Pudendal nerve block is used for local anesthesia during the second stage of labor, not for early labor pain relief. Attention-focusing techniques can help the client manage pain without pharmacological interventions, ensuring safety for both the client and the baby.
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 parent is receiving discharge teaching from a nurse regarding caring for their newborn after a circumcision. Which instruction should the nurse include?
- A. Apply slight pressure with a sterile gauze pad for mild bleeding.
- B. Inspect the circumcision site every 6 to 8 hours.
- C. Avoid using baby wipes containing alcohol to cleanse the penis with each diaper change.
- D. Clean the circumcision site daily using a warm, wet washcloth.
Correct Answer: A
Rationale: The correct answer is A: Apply slight pressure with a sterile gauze pad for mild bleeding. This instruction is crucial because it addresses the immediate post-circumcision care to control bleeding. Applying slight pressure with a sterile gauze pad helps to promote clotting and prevent excessive bleeding. This step is essential to ensure the newborn's safety and prevent complications.
Summary of other choices:
B: Inspecting the circumcision site every 6 to 8 hours is important, but not as critical as addressing bleeding promptly.
C: Avoiding baby wipes containing alcohol is a good practice to prevent irritation, but it is not the most urgent instruction for immediate care.
D: Cleaning the circumcision site daily using a warm, wet washcloth is generally recommended for routine care, but in the immediate post-circumcision period, controlling bleeding takes precedence.
A client with pregestational type 1 diabetes mellitus is being taught by a nurse about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should aim to maintain my fasting blood glucose between 100 and 120.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or higher.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will avoid exercise if my blood glucose exceeds 250.
Correct Answer: C
Rationale: The correct answer is C because continuing to take insulin during nausea and vomiting is crucial for maintaining blood glucose control in clients with diabetes. Nausea and vomiting can lead to decreased food intake, risking hypoglycemia if insulin is not adjusted.
Choice A is incorrect because fasting blood glucose levels should ideally be maintained between 60-90 mg/dL in pregnant clients with diabetes for optimal outcomes, not 100-120 mg/dL.
Choice B is incorrect because engaging in moderate exercise when blood glucose is high (250 or higher) can exacerbate hyperglycemia rather than help in lowering blood glucose levels.
Choice D is incorrect because avoiding exercise when blood glucose exceeds 250 is not recommended. Exercise can help lower blood glucose levels and improve insulin sensitivity.