Nokea
A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?
- A. Talipes equinovarus
- B. Fractured clavicle
- C. Congenital hypothyroidism
- D. Increased intracranial pressure
Correct Answer: B
Rationale: An asymmetrical Moro reflex suggests a possible fractured clavicle, as it indicates unilateral impairment of arm movement. Talipes equinovarus affects the feet, congenital hypothyroidism presents with systemic symptoms, and increased intracranial pressure would likely cause more global neurological signs.
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A client 12 weeks' pregnant comes to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cm cervical dilation. The nurse would document these findings as which of the following?
- A. Threatened abortion
- B. Imminent abortion
- C. Complete abortion
- D. Missed abortion
Correct Answer: B
Rationale: Imminent abortion is documented when there is abdominal cramping, moderate vaginal bleeding, and cervical dilation (2-3 cm), indicating inevitable pregnancy loss. Threatened abortion involves bleeding without dilation, complete abortion involves full expulsion of products, and missed abortion involves fetal demise without expulsion.
A nurse is caring for a client in labor. The nurse-midwife is performing an amniotomy. The nurse explains to the client that after this procedure, she will most likely have:
- A. Less pressure on her cervix
- B. Increased efficiency of contractions
- C. Decreased number of contractions
- D. The need for increased maternal blood pressure monitoring
Correct Answer: B
Rationale: Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
- A. Ask the client to turn on her side
- B. Ask the client to lie flat on her back with the knees and legs flat and straight.
- C. Ask the mother to urinate and empty her bladder
- D. Massage the fundus gently before determining the level of the fundus.
Correct Answer: C
Rationale: Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.
The uterus is a muscular, pear-shaped organ that is responsible for:
- A. Cyclic menstruation.
- B. Sex hormone production.
- C. Fertilization.
- D. Sexual arousal.
Correct Answer: A
Rationale: The uterus supports menstruation and pregnancy. Hormones and fertilization occur in ovaries, and arousal involves multiple systems, not primarily the uterus.
A multigravida at 38 weeks' gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?
- A. Maternal vital signs
- B. Fetal heart rate
- C. Contraction monitoring
- D. Cervical dilation
Correct Answer: D
Rationale: Cervical dilation assessment should be avoided in a multigravida with painless, bright red bleeding, as it suggests placenta previa, and a vaginal exam could exacerbate bleeding. Maternal vital signs, fetal heart rate, and contraction monitoring are safe and necessary.