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Newborn whose mother had gestational diabetes mellitus.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Jitteriness.
- B. Hypertonia.
- C. Acrocyanosis of the hands.
- D. Generalized petechiae.
Correct Answer: A
Rationale: Jitteriness indicates hypoglycemia in newborns as glucose is critical for neonatal brain function. Blood glucose less than 45 mg/dL supports this diagnosis, requiring prompt intervention to avoid neurological harm.
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Client with fibrocystic breast changes experiencing breast discomfort during menstruation.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase your potassium intake.
- B. Increase your fluid intake to 3 liters per day.
- C. Refrain from consuming alcohol.
- D. Limit your daily intake of fiber.
Correct Answer: C
Rationale: Alcohol consumption can worsen fibrocystic breast discomfort due to its estrogen-modulating effects, which may exacerbate hormonal fluctuations during menstruation, increasing breast pain and sensitivity.
Client at 35 weeks of gestation experiencing mild vaginal bleeding due to placenta previa.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A,B
Rationale: Continuous monitoring of fetal heart rate (A) provides early detection of distress in placenta previa cases. Betamethasone (B) accelerates fetal lung maturity, reducing the risk of respiratory distress syndrome if preterm delivery occurs.
Client at 31 weeks of gestation receiving magnesium sulfate via continuous IV infusion for preterm labor.
A nurse is assessing a client who is at 31 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for preterm labor. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate 11/min.
- B. Deep tendon reflexes 2+.
- C. Urine output 30 mL/hr.
- D. Blood pressure 100/62 mm Hg.
Correct Answer: A
Rationale: A respiratory rate of 11/min is below the normal adult range of 12–20/min and indicates respiratory depression, a potential adverse effect of magnesium sulfate requiring immediate intervention.
Client reports feeling well, findings include: General: No acute distress. Cardiovascular: No murmur or rub. Respiratory: Bilateral breath sounds clear. Abdomen: Fundal height 38 cm. Genitourinary: Purulent cervical discharge.
A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy. What additional care should the nurse consider?
- A. Administering prophylactic antibiotics to prevent infection.
- B. Assessing for signs of jaundice in the newborn.
- C. Monitoring the client's vital signs for stability.
- D. Educating the client on breastfeeding techniques.
Correct Answer: B
Rationale: Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.