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A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A. At 26 weeks of gestation, newborns are expected to have minimal arm recoil based on the New Ballard Score, as their muscle tone is typically low. This indicates immaturity and aligns with the developmental stage of a premature infant. The other choices are incorrect because: B: A popliteal angle of 90° is more indicative of a term infant. C: Creases over the entire foot sole are also seen in term infants, not premature infants. D: Raised areolas with 3 to 4 mm buds are associated with breast development in term infants, not preterm infants.
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A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is known to cause breast tenderness as a common adverse effect due to its estrogen-like effects. This occurs because clomiphene citrate can increase estrogen levels in the body, leading to breast discomfort. Tinnitus (B), urinary frequency (C), and chills (D) are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency may occur with diuretics, and chills are often seen with infections or febrile illnesses. Therefore, the nurse should emphasize breast tenderness as a potential side effect of clomiphene citrate to the client.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: Correct Answer: A. Administer broad-spectrum antibiotics.
Rationale: Administering broad-spectrum antibiotics is essential to prevent infection in the newborn with a leaking myelomeningocele. The exposed spinal cord increases the risk of infection, which can lead to serious complications such as meningitis. Antibiotics can help prevent or treat any potential infections.
Incorrect Choices:
B. Monitoring rectal temperature every 4 hours is not the priority in this situation. Infection prevention and management should take precedence.
C. Cleansing the site with povidone-iodine may not be appropriate as it can be irritating to the exposed spinal cord.
D. Surgical closure after 72 hours may be delayed if there is an infection present. Administering antibiotics is crucial before proceeding with surgical closure.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I will eat foods that taste good instead of balancing my meals."
- B. "I will avoid having a snack before I go to bed each night."
- C. "I will have a cup of hot tea with each meal."
- D. "I will eliminate products that contain dairy from my diet."
Correct Answer: D
Rationale: The correct answer is D: "I will eliminate products that contain dairy from my diet." This is correct because dairy products can exacerbate nausea and vomiting in hyperemesis gravidarum. Dairy is often harder to digest and can trigger gastrointestinal distress. Avoiding dairy can help reduce symptoms and improve tolerance to food.
Choice A is incorrect because focusing on taste over balanced nutrition is not advisable for someone with hyperemesis gravidarum. Choice B is irrelevant to the condition. Choice C is also not recommended as caffeine in tea can worsen nausea.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg
- B. Heart rate 98/min
- C. Urine output of 280 mL within 8 hr
- D. Urine negative for ketones
Correct Answer: D
Rationale: The correct answer is D: Urine negative for ketones. In hyperemesis gravidarum, excessive vomiting can lead to dehydration and ketosis. A negative urine ketone result indicates the client may not be adequately hydrated or receiving proper nutrition. This finding should be reported to the provider for further evaluation and intervention. Option A (Blood pressure 105/64 mm Hg) is within normal range for a pregnant woman. Option B (Heart rate 98/min) is slightly elevated but may be due to dehydration. Option C (Urine output of 280 mL within 8 hr) is inadequate and indicates poor fluid intake or excessive fluid loss. Reporting a negative urine ketone result is crucial to prevent further complications.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios
- B. Hyperemesis gravidarum
- C. Leukorrhea
- D. Periodic tingling of the fingers
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess fetal well-being by monitoring the baby's heart rate and uterine contractions. Oligohydramnios, which is low amniotic fluid levels, can indicate fetal distress and compromise, necessitating closer monitoring. Hyperemesis gravidarum (B) is severe nausea and vomiting, not directly related to fetal monitoring. Leukorrhea (C) is normal vaginal discharge during pregnancy and not a reason for fetal monitoring. Periodic tingling of the fingers (D) is unrelated to fetal assessment.