Nokea
A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?
- A. Place the newborn under a radiant warmer
- B. Apply oxygen
- C. Swaddle the newborn
- D. Reassess the newborn in 1 hour
Correct Answer: D
Rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a normal finding in newborns in the first few hours after birth. The nurse should continue to monitor the newborn and reassess after some time.
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A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Administer oral feedings
- B. Measure abdominal girth
- C. Position the newborn prone
- D. Apply warm compresses to the abdomen
Correct Answer: B
Rationale: Measuring abdominal girth is important in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). Other interventions include withholding oral feedings and providing IV fluids or nutrition.
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers
- B. Absence of clonus
- C. Leg cramps
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision can be an indicator of serious conditions such as preeclampsia, which involves hypertension and can lead to significant maternal and fetal complications.
A nurse is caring for a client who is 28 weeks pregnant and has preeclampsia. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct Answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption.
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
- A. Vitamin E
- B. Vitamin D
- C. Fiber
- D. Calcium
Correct Answer: D
Rationale: Calcium is vital during pregnancy for fetal bone development and to prevent maternal bone loss. The recommended daily intake should be increased to support these needs.
A nurse is caring for a client who is in the third trimester of pregnancy and has gestational diabetes. Which of the following complications is the fetus at risk for?
- A. Macrosomia
- B. Hydrocephalus
- C. Cleft palate
- D. Spina bifida
Correct Answer: A
Rationale: Gestational diabetes can result in fetal macrosomia, a condition where the baby grows larger than normal due to excess glucose in the mother's blood. This increases the risk of complications during delivery.