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A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of less than 90
- C. Creases over the entire sole
- D. Sparse lanugo
Correct Answer: B
Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.
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Which complication of adolescent pregnancy should the nurse plan to monitor?
- A. Anemia
- B. Placenta previa
- C. Abruptio placenta
- D. Incompetent cervix
Correct Answer: D
Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.
What two steps of the CJMM are included in the assessment step of the nursing process?
- A. noticing cues and evaluating outcomes
- B. analyzing cues and generating solutions
- C. noticing and analyzing cues
- D. analyzing cues and taking action
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.
A parent asks the nurse what makes the opening between the baby's atrium close at birth? The nurse's response is that cardiovascular changes that cause to foramen ovale to close at birth are the direct result of:
- A. Increased pressure in the L atrium (with the increase in the blood flow to the L atrium from the lungs, the pressure is
- C. Increased pressure in the R atrium
- D. Changes in the hepatic blood flow
Correct Answer: C
Rationale: The foramen ovale is a normal fetal structure that allows blood to bypass the lungs by shunting blood from the right atrium to the left atrium. This is essential during fetal development since the lungs are not functioning until birth. After birth, when the baby takes its first breaths and the lungs start working, the pressure in the left atrium increases due to the increased blood flow from the pulmonary circulation. This increased pressure in the left atrium causes the foramen ovale to close, preventing blood from flowing from the right atrium to the left atrium. Therefore, the closure of the foramen ovale is a result of the increased pressure in the left atrium rather than any other cardiovascular changes.
A client at 34 weeks' gestation reports regular uterine contractions. What is the nurse's priority action?
- A. Encourage ambulation to relieve discomfort.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Administer an analgesic as prescribed.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction pattern is crucial to evaluate for preterm labor.
What is contraceptive abstinence?
- A. mutual masturbation
- B. individual masturbation
- C. oral stimulation of the genitals
- D. avoiding penis-in-vagina intercourse
Correct Answer: D
Rationale: Contraceptive abstinence refers to avoiding penis-in-vagina intercourse to prevent pregnancy. It is a method of birth control where sexual partners choose not to engage in sexual intercourse during fertile periods to avoid the risk of pregnancy. This method relies on refraining from penetrative sex or any ejaculatory contact between the penis and vagina. It is a natural form of birth control and does not involve the use of contraceptives or devices.