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A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?
- A. Large deposits of subcutaneous fat
- B. Thin covering of fine hair on shoulders and back
- C. Nails extending over tips of fingers
- D. Pale, translucent skin
Correct Answer: C
Rationale: The correct answer is C: Nails extending over tips of fingers. Postterm newborns have longer nails due to the extended intrauterine period. Large deposits of subcutaneous fat (A) are common in term and postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (B) is typical in preterm newborns, not postterm. Pale, translucent skin (D) is seen in preterm infants, not postterm. Therefore, the most appropriate finding to expect in a postterm newborn is nails extending over tips of fingers.
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A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule involves adding 7 days to the first day of the last menstrual period, subtracting 3 months, and then adding 1 year. In this case, starting from August 10, add 7 days to get August 17. Next, subtract 3 months to get May 17, and finally add 1 year to get the estimated date of delivery as May 17. Choice A (May 13) is incorrect as it does not follow the correct calculation steps. Choice C (May 3) is incorrect as it miscalculates the months. Choice D (May 20) is incorrect as it does not consider the subtraction of 3 months.
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Vitamin B12 is mainly found in animal products, making it challenging for vegans to obtain sufficient amounts. Fortified soy milk is a great source of vitamin B12 for vegans. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12. It is important for the nurse to recommend a food source that is rich in vitamin B12 to help the client meet their nutritional needs.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face
- B. A newborn who is 32 hr old and has not passed a meconium stool
- C. A newborn who is 12 hr old and has pink-tinged urine
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7°C (99.9°F)
Correct Answer: B
Rationale: The correct answer is B because failure to pass meconium within 24-48 hours can indicate a bowel obstruction or other serious issue that needs immediate attention. A: Erythema toxicum is a common benign rash in newborns. C: Pink-tinged urine can be due to uric acid crystals and is normal in newborns. D: An axillary temperature of 37.7°C (99.9°F) is within normal range for a newborn.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates a lack of uterine tone, which can lead to postpartum hemorrhage. Administering oxytocin helps to stimulate contractions, restoring uterine tone and reducing bleeding. Excess vaginal bleeding is also an indication for oxytocin as it helps to control bleeding by promoting uterine contractions. Choices B, D, and the remaining options do not directly relate to the need for oxytocin administration in postpartum care. A cervical laceration would require appropriate wound management, and increased afterbirth cramping may not necessarily warrant oxytocin administration unless coupled with other signs of uterine atony.
A nurse is collecting data from a client who is at 30 weeks of gestation. Which of the following findings should the nurse identify as a manifestation of pyelonephritis?
- A. Epigastric discomfort
- B. Flank pain
- C. Temperature 37.7°C (99.8°F)
- D. Abdominal cramping
Correct Answer: B
Rationale: The correct answer is B: Flank pain. Pyelonephritis is an infection of the kidneys commonly characterized by flank pain. At 30 weeks of gestation, the uterus enlarges and can lead to obstruction of the ureters, increasing the risk of urinary stasis and infection. Epigastric discomfort (choice A) is more indicative of issues like preeclampsia. Temperature elevation (choice C) can be a sign of infection but is not specific to pyelonephritis. Abdominal cramping (choice D) is more likely related to uterine contractions or gastrointestinal issues.