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A nurse is assessing a newborn who was born Post term. Which of the following findings should the nurse expect?
- A. Nails extending over tips of fingers
- B. Large deposits of subcutaneous fat
- C. Pale, translucent skin
- D. Thin covering of fine hair on shoulders and back
Correct Answer: A
Rationale: The correct answer is A - Nails extending over tips of fingers. Post-term newborns may have longer nails due to prolonged exposure in utero. This is because the baby had more time for nail growth compared to a term baby. Nails extending over the tips of the fingers is a common finding in post-term newborns. The other choices are incorrect because large deposits of subcutaneous fat (B) are more common in term or postmature infants, pale, translucent skin (C) is more characteristic of preterm infants, and a thin covering of fine hair on shoulders and back (D) is typical of lanugo, which is usually shed before birth or shortly after for post-term infants.
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A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice A) is more indicative of neurological issues. Sweating (choice C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: A
Rationale: The correct answer is A: Contractions last 60 seconds. Prolonged contractions can lead to uterine hyperstimulation, which can decrease oxygen supply to the fetus, posing a risk of fetal distress. Discontinuing oxytocin in this situation is crucial to prevent further complications.
B: Non-repetitive early decelerations are not directly related to oxytocin administration and do not warrant discontinuation of the medication.
C: 6 contractions in 10 minutes is a sign of uterine hyperstimulation but alone may not be enough to discontinue oxytocin.
D: Moderate variability of the fetal heart rate is a reassuring sign of fetal well-being, not an indication to discontinue oxytocin.
A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Negele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
- A. December 15
- B. October 30
- C. January 15
- D. Nov 30
Correct Answer: A
Rationale: To calculate the estimated due date using Negele's rule, we add 7 days to the first day of the last menstrual period, subtract 3 months, and then add a year. March 8 + 7 days = March 15. Subtracting 3 months gives us December 15. Adding a year gives the estimated due date as December 15. This is the correct answer as it follows the standard calculation method. Other choices are incorrect as they do not follow the correct formula or have errors in calculation.
A nurse caring for a client who is at 20 weeks of gestation and has trichomoniasis. Which of the following findings should the nurse expect?
- A. Thick, White Vaginal Discharge
- B. Urinary Frequency
- C. Vulva Lesions
- D. Malodorous Discharge
Correct Answer: D
Rationale: The correct answer is D: Malodorous Discharge. Trichomoniasis is a sexually transmitted infection caused by a parasite, typically presenting with a foul-smelling, greenish-yellow vaginal discharge. This discharge is a hallmark symptom of trichomoniasis due to inflammation and infection of the vaginal mucosa. Other choices are incorrect because: A) Thick, White Vaginal Discharge is more indicative of a yeast infection; B) Urinary Frequency is not a common symptom of trichomoniasis; C) Vulva Lesions are not typically associated with trichomoniasis at 20 weeks of gestation.
A nurse is reviewing the laboratory results of a newborn. Which of the following findings should the nurse report to the provider?
- A. Blood glucose 58 mg/dL
- B. Hematocrit 48%
- C. Platelets 100,000/mm³
- D. Hemoglobin 16 g/dL
Correct Answer: C
Rationale: The correct answer is C: Platelets 100,000/mm³. This finding should be reported as it indicates a low platelet count, which can lead to bleeding issues in the newborn. A normal platelet count in a newborn is typically higher than 150,000/mm³. Low platelets can increase the risk of bleeding, especially in the setting of birth trauma.
A: Blood glucose 58 mg/dL is within the normal range for a newborn.
B: Hematocrit 48% is within the normal range for a newborn.
D: Hemoglobin 16 g/dL is within the normal range for a newborn.
In summary, the correct answer is C because it signifies a potential health concern for the newborn, while the other options fall within normal ranges and do not require immediate medical attention.