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A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.
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A nurse is caring for a client who reports spontaneous rupture. The nurse observed fetal bradycardia in the FHR tracing and notices the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following should the nurse take next?
- A. Initiate an infusion of IV fluids for the client
- B. Perform vaginal examination by applying upward pressure on the presenting part
- C. Administer oxygen via non-rebreather mask at 8 L/min
- D. Cover the umbilical cord with sterile saline saturated towel
Correct Answer: D
Rationale: The correct answer is D: Cover the umbilical cord with sterile saline saturated towel. This step is crucial to prevent compression of the umbilical cord and maintain blood flow to the fetus, reducing the risk of fetal distress. It also helps in preventing infection and protecting the exposed cord.
Choice A: Initiating an infusion of IV fluids is not the priority in this situation as the immediate concern is to protect the umbilical cord and ensure fetal well-being.
Choice B: Performing a vaginal examination could further worsen the situation by putting pressure on the umbilical cord, leading to decreased blood flow to the fetus.
Choice C: Administering oxygen is important in fetal distress, but covering the umbilical cord takes precedence in this case to prevent further complications.
In summary, covering the umbilical cord with a sterile saline-saturated towel is the correct action to protect the cord and maintain fetal perfusion.
A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level
Correct Answer: B
Rationale: The correct answer is B: Apply a cap to the newborn's head. This action helps prevent heat loss through the newborn's head, which is a common area for heat loss in newborns. The respiratory rate of 50/min and heart rate of 130/min are within normal ranges for a newborn. The temperature of 36.1°C (97°F) is slightly lower than the normal range, so keeping the newborn warm is important. Giving a warm bath (choice A) may further decrease the newborn's body temperature. Repositioning the newborn (choice C) may not address the issue of heat loss. Obtaining an oxygen saturation level (choice D) is not indicated based on the information provided. Therefore, applying a cap to the newborn's head is the most appropriate action to help maintain the newborn's body temperature and prevent heat loss.
A nurse is caring for a client who has received an epidural during labor. Which of the following actions should the nurse take?
- A. Position a wedge under the clients left hip
- B. Place the client in the lithotomy position
- C. Assist the client to a knee chest position
- D. Elevate the head of the client’s bed to 90%
Correct Answer: A
Rationale: The correct answer is A: Position a wedge under the client's left hip. Placing a wedge under the left hip helps to optimize the distribution of the epidural medication, ensuring even pain relief. This positioning can also help prevent uneven spread of the medication, reducing the risk of complications such as uneven numbness or motor weakness.
Choice B: Placing the client in the lithotomy position is incorrect because this position is not recommended for clients with epidurals as it may increase the risk of hypotension.
Choice C: Assisting the client to a knee-chest position is incorrect because this position is not suitable for clients with epidurals and may cause discomfort or compromise the effectiveness of the epidural.
Choice D: Elevating the head of the client's bed to 90% is incorrect as it is not directly related to optimizing the effects of the epidural.
In summary, positioning a wedge under the client's left hip is the most appropriate action to ensure optimal distribution and effectiveness
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 is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client’s nipple when not breastfeeding
- B. Ensure the newborn’s mouth is wide open before latching to the breast
- C. Encourage the client to limit the newborn’s feeding to 10 min on each breast
- D. Instruct the client to begin the feeding with the nipple that is most tender
Correct Answer: B
Rationale: The correct answer is B: Ensure the newborn’s mouth is wide open before latching to the breast. This is the correct action to take to address sore nipples from breastfeeding. Ensuring a wide latch helps the baby to properly attach to the breast, reducing the pressure on the nipple and preventing further damage. A snug dressing (Option A) can worsen the condition by obstructing airflow and promoting moisture. Limiting feeding time (Option C) can lead to inadequate milk supply or poor weight gain. Starting with the most tender nipple (Option D) can prolong healing.