Nokea
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to substances, such as methadone, while in the womb. Infants with NAS may exhibit excessive high-pitched crying as one of the manifestations. Other common symptoms of NAS include irritability, tremors, feeding difficulties, sweating, fever, vomiting, diarrhea, and poor weight gain. Therefore, in this case, the excessive high-pitched cry is a manifestation that the nurse should identify as an indication of neonatal abstinence syndrome.
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Which is the most dangerous effect on the fetus of a patient who smokes cigarettes while pregnant?
- A. Intrauterine growth restriction
- B. Genetic changes and anomalies
- C. Extensive central nervous system damage
- D. Fetal addiction to the substance inhaled
Correct Answer: A
Rationale: Smoking cigarettes during pregnancy is known to have harmful effects on the fetus, with one of the most serious consequences being intrauterine growth restriction (IUGR). IUGR occurs when the fetus does not grow at a normal rate inside the womb, leading to a lower birth weight. This can have long-term implications on the overall health and development of the baby, including increased risk of various health problems later in life such as respiratory issues, cardiovascular disease, and metabolic disorders. In severe cases, IUGR can even result in stillbirth or neonatal death. Therefore, it is crucial for pregnant individuals to avoid smoking to protect the health and well-being of their unborn child.
Which assessment finding indicates uterine rupture?
- A. Ctx abruptly stop during labor
- B. Fetal tachycardia occurs
- C. Client becomes dyspneic
- D. Labor progressing unusually quickly
Correct Answer: A
Rationale: Uterine rupture is a rare but serious obstetric emergency that can occur during labor and delivery. One of the key assessment findings indicating uterine rupture is when contractions (ctx) abruptly stop during labor. This abrupt cessation of contractions can be a sign that the uterine muscle has torn due to excessive pressure or force, leading to a disruption in the normal progress of labor. Other signs and symptoms of uterine rupture may include severe abdominal pain, abnormal fetal heart rate patterns, loss of fetal station, and signs of hypovolemic shock in the mother. Immediate intervention and surgical management are required in cases of uterine rupture to ensure the safety of both the mother and the baby.
The nurse is assessing a client with suspected gestational hypertension. What finding supports this diagnosis?
- A. Blood pressure of 150/90 mmHg.
- B. Proteinuria of +2.
- C. Fetal heart rate of 140 beats/minute.
- D. Mild edema in the lower extremities.
Correct Answer: A
Rationale: Gestational hypertension is diagnosed with a blood pressure of 140/90 mmHg or higher without proteinuria.
The nurse is teaching a prenatal class about labor. What statement indicates understanding?
- A. True labor contractions are irregular and stop with rest.
- B. False labor contractions cause cervical dilation.
- C. True labor contractions increase in intensity and frequency.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor contractions become progressively stronger and lead to cervical dilation and effacement.
A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?
- A. A client who has a urinary output of 300 ml in 8 hr.
- B. A client who reports abdominal cramping during breastfeeding
- C. A client who is receiving magnesium sulfate and has absent deep tendon reflexes
- D. A client who reports lochia rubra requiring changing perineal pads every 3 hr.
Correct Answer: C
Rationale: The nurse should notify the provider for the client who is receiving magnesium sulfate and has absent deep tendon reflexes. Absent deep tendon reflexes are a sign of magnesium toxicity, which can lead to serious complications such as respiratory depression, cardiac arrest, and death. Prompt intervention by the provider is necessary to adjust the magnesium sulfate dosage and prevent further harm to the client.