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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 their prolonged growth in utero. This is a common finding in babies born after 42 weeks gestation. Large deposits of subcutaneous fat (choice A) are typically seen in term or postterm newborns, not specific to postterm. Thin covering of fine hair on shoulders and back (choice B) is known as lanugo, which is present in premature infants, not postterm. Pale, translucent skin (choice D) is more common in premature infants, not postterm.
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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 a medication commonly used to treat infertility by stimulating ovulation. Breast tenderness is a common side effect due to the hormonal changes it induces, as it can lead to increased estrogen levels. This is important for the nurse to include in teaching as it prepares the client for a potential adverse effect.
B: Tinnitus, C: Urinary frequency, D: Chills are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency is not a known side effect of clomiphene, and chills are not a typical reaction to this medication. It is essential for the nurse to focus on the most relevant and common adverse effects to ensure the client's understanding and safety.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.
A nurse is teaching about home safety with a client who is 2 days postpartum. Which of the following instructions should the nurse include in the teaching?
- A. Bathe your baby immediately after a feeding.
- B. Place a bumper pad in your baby’s crib.
- C. Put a soft mattress in your baby’s crib.
- D. Wash your baby’s face with plain water.
Correct Answer: D
Rationale: The correct answer is D: Wash your baby's face with plain water. This instruction is important because it helps prevent irritation or infection on the baby's delicate skin. Washing the baby's face with plain water is gentle and safe for newborns.
A: Bathing the baby immediately after a feeding is not recommended as it may lead to discomfort or spitting up.
B: Placing a bumper pad in the baby's crib can pose a suffocation hazard for the newborn.
C: Putting a soft mattress in the baby's crib increases the risk of sudden infant death syndrome (SIDS) as it may cause suffocation.
Overall, washing the baby's face with plain water is the safest and most appropriate instruction for home safety with a 2-day postpartum client.
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. Maternal cytomegalovirus can be transmitted to the newborn through contact with infected bodily fluids such as saliva and urine. This is important for the nurses to understand as they care for both the mother and the newborn to prevent transmission.
Choice A is incorrect because acyclovir is not used to treat cytomegalovirus, but rather for other viral infections like herpes. Choice C is incorrect because lesions are not typically visible on the mother's genitalia with cytomegalovirus. Choice D is incorrect because airborne precautions are not necessary for cytomegalovirus transmission.
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. Soy milk is often fortified with vitamin B12, making it a suitable option for a client following a vegan diet. Vitamin B12 is primarily found in animal products, so vegans need to ensure they get an adequate intake from fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and would not be effective in increasing intake. A detailed explanation is crucial in guiding the client to make informed choices for their dietary needs.