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A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Absent plantar reflexes
- C. Lengthened thigh on the affected side
- D. Asymmetric thigh folds
Correct Answer: D
Rationale: The correct answer is D: Asymmetric thigh folds. In DDH, there is an abnormal formation of the hip joint which can lead to dislocation. Asymmetric thigh folds result from the shortened thigh muscles on the affected side due to the dislocation. This finding is indicative of DDH as it reflects the displacement of the femoral head. The other choices are incorrect because an inwardly turned foot (A) is associated with clubfoot, absent plantar reflexes (B) may indicate neurological issues, and a lengthened thigh (C) is not a typical finding in DDH.
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A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care after birth?
- A. Observe for meconium in respiratory secretions.
- B. Monitor for hyperthermia.
- C. Identify manifestations of anemia.
- D. Monitor for hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Observe for meconium in respiratory secretions. This is important because infants who are small for gestational age (SGA) are at increased risk for meconium aspiration syndrome due to their underdeveloped lungs. Meconium in respiratory secretions can lead to respiratory distress and requires immediate intervention.
Choice B, monitoring for hyperthermia, is incorrect as it is not specifically related to SGA infants. Choice C, identifying manifestations of anemia, is also incorrect as SGA infants may have normal hematologic parameters. Choice D, monitoring for hyperglycemia, is not directly associated with SGA infants and is more relevant to infants of diabetic mothers.
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 48/min
- B. 22/min
- C. 100/min
- D. 110/min
Correct Answer: A
Rationale: The correct answer is A: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. Choice A falls within this range, indicating a normal respiratory rate for the newborn. Choices B, C, and D are outside the expected reference range. Choice B (22/min) is too low, while choices C (100/min) and D (110/min) are too high, which could indicate respiratory distress or other underlying issues in the newborn. It is important for the nurse to monitor the newborn closely and further assess if the respiratory rate is outside the normal range.
A male newborn infant has just been circumcised. The nurse checks the surgical site, expecting it to have what appearance?
- A. Reddened with a small amount of bloody drainage.
- B. Pink without drainage.
- C. Reddened with a scant amount of yellow exudate.
- D. Reddened, with copious blood.
Correct Answer: C
Rationale: The correct answer is C: Reddened with a scant amount of yellow exudate. After circumcision, it is normal for the surgical site to appear reddened due to the inflammatory response. The presence of a scant amount of yellow exudate indicates normal wound healing with minimal discharge. This is a sign of the body's natural process of cleansing the wound. Choices A and D are incorrect because copious blood or bloody drainage would be abnormal and may indicate bleeding complications. Choice B is incorrect as pink without drainage would not be expected immediately after circumcision. In choice A, while some bloody drainage may be expected, the presence of yellow exudate is more indicative of normal healing.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Place the client in knee-chest position.
- C. Prepare the client for an immediate birth.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord.
Correct Answer: D
Rationale: The correct answer is D: Insert a gloved hand into the vagina to relieve pressure on the cord. This is the priority action in this situation to prevent cord compression, which can compromise fetal blood flow. By gently elevating the presenting part off the cord, the nurse can help restore blood flow to the baby. Covering the cord (A) or placing the client in the knee-chest position (B) are not as effective in relieving pressure on the cord. Preparing for an immediate birth (C) may be necessary but addressing the cord issue is the priority.