Nokea
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can result in weakness or paralysis of facial muscles. Polycythemia (choice A) is not typically associated with forceps-assisted births. Hypoglycemia (choice B) may occur in newborns for various reasons, but it is not directly related to the birth method. Bronchopulmonary dysplasia (choice C) is a lung condition usually seen in premature infants, not specifically linked to forceps deliveries. In summary, facial palsy is the most likely complication of forceps-assisted births due to the pressure exerted on the baby's face during the delivery process.
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A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is crucial because the occipitoposterior position can cause intense back pain during labor. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve the client's discomfort. A: "Does that lessen your suprapubic pain?" is incorrect because suprapubic pain is not specifically associated with occipitoposterior positioning. B: "Are you feeling relief from your pelvic pressure?" is incorrect as it does not directly address the back pain associated with occipitoposterior positioning. C: "Do your contractions feel further apart?" is incorrect as it does not focus on the back pain issue. The key is to address the specific discomfort caused by the occipitoposterior position.
A nurse in a provider’s office is caring for a 20-year-old client who is at 12 weeks of gestation and requests an amniocentesis to determine the sex of the fetus. Which of the following responses should the nurse make?
- A. You cannot have an amniocentesis until you are at least 35 years of age.
- B. This procedure determines if your baby has genetic or congenital disorders.
- C. Your provider will schedule a chorionic villus sampling to determine the sex of your baby.
- D. We can schedule the procedure for later today if you’d like.
Correct Answer: B
Rationale: The correct answer is B: This procedure determines if your baby has genetic or congenital disorders. At 12 weeks of gestation, amniocentesis is typically not done to determine the sex of the fetus but rather to identify genetic abnormalities or congenital disorders. Providing this information allows the client to make informed decisions about their pregnancy and potential interventions.
A: You cannot have an amniocentesis until you are at least 35 years of age - This statement is incorrect as age alone is not the sole criteria for recommending amniocentesis.
C: Your provider will schedule a chorionic villus sampling to determine the sex of your baby - Chorionic villus sampling is also not typically done to determine the sex of the fetus.
D: We can schedule the procedure for later today if you’d like - This is incorrect as scheduling an amniocentesis without a medical indication is not appropriate.
A nurse is providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. This statement indicates an understanding of tubal ligation, which is a permanent method of contraception that prevents pregnancy by blocking the fallopian tubes. Ovulation, the release of an egg from the ovary, will continue to occur after tubal ligation. This is because tubal ligation does not affect the hormonal process of ovulation.
Choice A is incorrect because premenstrual tension can still occur even after tubal ligation. Choice B is incorrect as tubal ligation does not affect the duration of menstrual periods. Choice C is incorrect because hormone replacements are not typically needed after tubal ligation unless there are other underlying medical conditions.
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its large muscle mass, minimal nerves and blood vessels, and reduced risk of hitting bone. It is located on the lateral aspect of the thigh and is easily accessible for injections. This site also allows for proper absorption of the medication. The other options are not ideal for newborns: B: Dorsogluteal is not recommended due to the risk of damaging the sciatic nerve, C: Deltoid is typically used for older children and adults, and D: Rectus femoris is not a common site for IM injections in newborns.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to monitor fetal heart rate and movement patterns. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, providing valuable information about the fetal well-being. Maintaining the client NPO (Option A) is not necessary for a nonstress test. Placing the client in a supine position (Option B) can decrease blood flow to the fetus. Instructing the client to massage the abdomen (Option C) may lead to inaccurate test results.