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: Substernal retractions are a sign of respiratory distress in newborns and require immediate medical attention to ensure proper oxygenation.
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What is the recommended method of pain relief during labor for a woman with a low-risk pregnancy?
- A. Epidural anesthesia
- B. Spinal anesthesia
- C. Nitrous oxide inhalation
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: Nitrous oxide inhalation. This is recommended for low-risk pregnancies because it provides pain relief without affecting the baby's heart rate or the progress of labor. It is self-administered by the woman, allowing for control over the dosage. Epidural and spinal anesthesia carry potential risks and may interfere with the natural process of labor. Choosing "All of the above" (D) is incorrect as epidural and spinal anesthesia are not recommended for low-risk pregnancies due to their potential side effects.
Which of the following is a potential complication of a breech delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Birth trauma
- D. All of the above
Correct Answer: C
Rationale: The correct answer is C: Birth trauma. In a breech delivery, where the baby is positioned feet or buttocks first, there is an increased risk of birth trauma due to potential difficulties in delivering the baby's head, leading to possible injuries such as fractures or nerve damage. Fetal distress and maternal hemorrhage can also occur but are not exclusive complications of breech delivery. Choice D, "All of the above," is incorrect as not all potential complications of a breech delivery are listed.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to inadequate energy supply to the respiratory muscles, resulting in respiratory distress. Hypertonia (A) is not a typical manifestation of hypoglycemia in newborns. Increased feeding (B) is a common response to hunger but not a direct indication of hypoglycemia. Hyperthermia (C) is not a typical sign of hypoglycemia. In summary, respiratory distress is a key clinical manifestation of hypoglycemia in late preterm newborns, making it the correct choice.
Which of the following is a potential complication of maternal obesity during pregnancy?
- A. Gestational diabetes
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: D
Rationale: Maternal obesity can lead to gestational diabetes, preterm labor, and fetal macrosomia.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client’s condition to the local health department.
Correct Answer: D
Rationale: Reporting the client’s HIV status to the local health department is a legal requirement to ensure proper public health tracking and intervention.