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A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
- A. Molding
- B. Vernix Caseosa
- C. Acrocyanosis
- D. Sternal retractions
Correct Answer: D
Rationale: The correct answer is D: Sternal retractions. Sternal retractions in a newborn indicate respiratory distress, potentially due to a blocked airway or difficulty breathing. The nurse should intervene immediately to ensure the newborn's airway is clear and that they are able to breathe properly.
A: Molding is the overlapping of cranial bones during birth, a common and temporary finding.
B: Vernix Caseosa is a protective coating on the newborn's skin and is normal.
C: Acrocyanosis is the bluish discoloration of the hands and feet, a common finding in newborns due to immature circulation.
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A nurse in a woman’s health clinic is obtaining a health history from a client. Which of the following findings should the nurse identify as increasing the client’s risk for developing pelvic inflammatory disease (PID)?
- A. Recurrent Cystitis
- B. Frequent Alcohol Use
- C. Use of Oral Contraceptives
- D. Chlamydia Infection
Correct Answer: D
Rationale: The correct answer is D: Chlamydia Infection. Chlamydia is a common sexually transmitted infection that can lead to PID if left untreated. The bacteria can ascend from the cervix to the upper genital tract, causing inflammation and scarring. This increases the risk of PID. Recurrent Cystitis (A) is a urinary tract infection and not directly related to PID. Frequent Alcohol Use (B) does not directly increase the risk of developing PID. Use of Oral Contraceptives (C) actually decreases the risk of PID by reducing the chances of getting sexually transmitted infections.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I should position my baby’s car seat at a 45-degree angle in the car.”
- B. “I should place the car seat rear facing until my baby is 12 months old.”
- C. “I should place the harness snugly in a slot above my baby’s shoulders.”
- D. “I should position the retainer clip at the top of my baby’s abdomen.”
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.
A nurse is teaching a prenatal class regarding false labor. Which of the following information should the nurse include?
- A. your contraction will become more intense when walking
- B. you will have dilation and effacement of the cervix
- C. You will have bloody show
- D. Your contraction will become temporally regular
Correct Answer: A
Rationale: The correct answer is A: your contractions will become more intense when walking. This is because false labor contractions typically decrease in intensity or stop completely when the individual changes positions or engages in physical activity. This is a key characteristic that helps differentiate false labor from true labor. Choices B, C, and D are incorrect as they are more indicative of true labor, where there is cervical dilation, effacement, bloody show, and regular contractions. It is important for the nurse to emphasize this distinction to ensure pregnant individuals can recognize the signs of true labor and seek appropriate care.
A nurse is assisting with an amniotomy on a client who is in labor. Which of the following situations should the nurse take?
- A. Place the client in the left lateral position
- B. Ensure that the fetal head is engaged
- C. Give the provider clean gloves during the procedure
- D. Check the clients temperature every 4 hours after the procedure
Correct Answer: B
Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice D) is important for monitoring but not a priority before an amniotomy.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.