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A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?
- A. A client who is at 11 weeks of gestation and reports abdominal cramping.
- B. A client who is at 15 weeks of gestation and reports tingling and numbness in right hand.
- C. A client who is at 20 weeks of gestation and reports constipation for the past 4 days.
- D. A client who is at 8 weeks of gestation and reports having three bloody noses in the past week.
Correct Answer: A
Rationale: The correct answer is A: A client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping in early pregnancy could indicate a potential threat of miscarriage or ectopic pregnancy, which require immediate assessment to ensure the safety of the client and the pregnancy. Clients experiencing this symptom need prompt evaluation to rule out any serious complications. Choices B, C, and D do not pose immediate risks to the client or the pregnancy and can be addressed after ensuring the safety of the client in choice A. Numbness and tingling in the hand (choice B) may be due to carpal tunnel syndrome, while constipation (choice C) and bloody noses (choice D) are common pregnancy symptoms that can be managed through non-urgent interventions.
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A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: The correct answer is A: Decrease the lighting levels in the nursery. Neonatal abstinence syndrome causes sensitivity to stimuli, including light. By decreasing lighting levels, the nurse can help reduce overstimulation and promote a calm environment for the newborn. This can aid in soothing the baby and decreasing symptoms associated with the syndrome.
Choice B is incorrect because wrapping the newborn loosely in a blanket may not directly address the sensitivity to light and other stimuli. Choice C, providing frequent stimulation, would likely exacerbate the symptoms of neonatal abstinence syndrome due to the increased sensory input. Choice D, encouraging frequent eye contact during feedings, could also lead to overstimulation for the newborn.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face.
- B. A newborn who is 32 hr old and has not passed a meconium stool.
- C. A newborn who is 12 hr old and has pink-tinged urine.
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F).
Correct Answer: B
Rationale: The correct answer is B. A newborn who is 32 hr old and has not passed a meconium stool should be reported to the provider. Meconium should be passed within the first 24-48 hours of life, so the delay could indicate an obstruction or other issue. Choices A, C, and D are all within normal ranges for newborn assessments and do not require immediate reporting to the provider. E, F, and G are not provided as options.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: The correct answer is D: You should press the handheld button when you feel your baby move. In a nonstress test, the client is required to press a handheld button whenever they feel the baby move. This action helps to correlate fetal movements with changes in the fetal heart rate, allowing healthcare providers to assess the baby's well-being. This active participation from the client ensures accurate monitoring of the baby's condition. The other choices are incorrect because: A: The duration of a nonstress test can vary but typically takes around 20-40 minutes. B: Lying in a supine position is not recommended during pregnancy as it can decrease blood flow to the baby. C: It is important for the client to have a light meal before the test to ensure the baby is active during monitoring.
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for proper identification and prevention of mix-ups. Matching the identification bands ensures that the newborn is going to the correct parent, enhancing safety.
Choice B is incorrect because asking the parent to verify their own information does not confirm the identification of the newborn. Choice C is incorrect as it focuses on the security tag number, which may not be as reliable as the identification bands. Choice D is incorrect as matching the date and time of birth to the parent's medical record does not provide direct confirmation of the parent-newborn match.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. This phase is characterized by more rapid cervical dilation (6-10 cm) and increased contractions with shorter intervals. The client's symptoms align with this phase as they are experiencing strong contractions close together, along with increased rectal pressure indicating descent of the fetus. Other choices are incorrect as: A (Passive descent) occurs during the second stage of labor; C (Early phase) is typically before 6 cm dilation; D (Descent) is not a recognized phase of labor.