Nokea
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn can indicate respiratory distress, which is a critical finding that requires immediate attention from the provider to prevent complications. Acrocyanosis (B) is a common finding in newborns and usually resolves on its own. Overlapping suture lines (C) can be normal in newborns due to the molding process during birth. The head circumference of 33 cm (13 in) (D) is within the normal range for a newborn.
You may also like to solve these questions
A nurse is caring for a client who is receiving an epidural block with an opioid analgesic. The nurse should monitor for which of the following findings as an adverse effect of the medication?
- A. Hyperglycemia
- B. Bilateral crackles
- C. Hypotension
- D. Polyuria
Correct Answer: C
Rationale: Correct Answer: C - Hypotension
Rationale: Opioid analgesics can cause hypotension as a side effect by vasodilation and reduced cardiac output. The epidural route can further exacerbate this effect due to the potential spread of the medication to sympathetic nerves, resulting in vasodilation and decreased blood pressure. Monitoring for hypotension is crucial to prevent complications such as decreased tissue perfusion and potential cardiovascular collapse.
Incorrect Choices:
A: Hyperglycemia - Opioids do not typically cause hyperglycemia.
B: Bilateral crackles - Crackles are not a common adverse effect of opioids.
D: Polyuria - Opioids do not usually cause polyuria.
Which of the following is a potential complication of a vacuum-assisted delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Intra-abdominal injury
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: Intra-abdominal injury. During a vacuum-assisted delivery, the vacuum extractor can potentially apply excessive force leading to intra-abdominal injury to the mother. This can include injuries to the uterus, bladder, or other abdominal organs. Fetal distress (choice A) and maternal hemorrhage (choice B) are potential complications of vacuum-assisted delivery as well, but they are not directly related to the mechanical trauma that can cause intra-abdominal injury. Therefore, the correct answer is C as it specifically addresses a unique complication associated with vacuum-assisted delivery.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I should increase my protein intake to 60 grams each day."
- B. "I should drink 2 liters of water each day."
- C. "I should increase my overall daily caloric intake by 300 calories."
- D. "I should take 600 micrograms of folic acid each day."
Correct Answer: A
Rationale: The correct answer is A because protein is essential for fetal development and increasing protein intake to 60 grams per day is recommended during pregnancy for optimal growth. Adequate protein intake helps in the formation of new tissues and cells.
Choice B is incorrect because while staying hydrated is important during pregnancy, the specific amount of 2 liters per day is not a standard recommendation and may vary depending on individual needs.
Choice C is incorrect as increasing overall daily caloric intake by 300 calories is a general guideline, not specific to the client's gestational age.
Choice D is incorrect as while folic acid is crucial during pregnancy to prevent birth defects, the recommended daily intake is usually 400-800 micrograms, so 600 micrograms is within the range but not the best answer.
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
- A. Monitor blood pressure.
- B. Initiate contact precautions.
- C. Prepare for amniocentesis .
- D. Apply internal fecal monitor.
- E. Decrease lighting in the client's room
- F. Check urinary output.
- G. Encourage bed rest.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)
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 response is B: This procedure determines if your baby has genetic or congenital disorders. Amniocentesis is a diagnostic test that involves taking a sample of the amniotic fluid, which can be analyzed for genetic abnormalities like Down syndrome. It is typically performed between 15-20 weeks of gestation, not based on maternal age. Choice A is incorrect as there is no age requirement for amniocentesis. Choice C is incorrect as chorionic villus sampling is a different procedure used for genetic testing earlier in pregnancy. Choice D is incorrect as amniocentesis is a planned procedure that requires preparation and scheduling, not something to be done on the same day.