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A nurse is assisting with an amniotomy on a client who is in labor. Which of the following situations should the nurse take?
- A. Place the client in the left lateral position
- B. Ensure that the fetal head is engaged
- C. Give the provider clean gloves during the procedure
- D. Check the clients temperature every 4 hours after the procedure
Correct Answer: B
Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice D) is important for monitoring but not a priority before an amniotomy.
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis
- B. Single palmar creases
- C. Subconjunctival hemorrhage
- D. Rust-stained urine
Correct Answer: B
Rationale: The correct answer is B: Single palmar creases. This finding may indicate the presence of Down syndrome or other genetic disorders. The presence of single palmar creases warrants further evaluation by the provider to rule out any underlying conditions. Transient circumoral cyanosis, subconjunctival hemorrhage, and rust-stained urine are common and typically benign findings in newborns that do not require immediate reporting.
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn’s visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: The correct answer is D: Swaddle the newborn in a flexed position. This intervention helps provide comfort and security to the newborn, which can help reduce symptoms of neonatal abstinence syndrome. Swaddling in a flexed position mimics the womb environment, promoting relaxation and reducing irritability.
A: Increasing visual stimulation can overwhelm the newborn and exacerbate symptoms.
B: Weighing the newborn every other day is not directly related to managing neonatal abstinence syndrome.
C: Discouraging parental interaction can hinder bonding and support, which are crucial for the newborn's well-being.
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
A nurse is providing nutritional guidance to a client who is pregnant and follows a vegan diet. The client asks the nurse which foods she should eat to ensure adequate calcium intake. The nurse should instruct the client that which of the following foods has the highest amount of calcium?
- A. ½ cup cubed avocado
- B. 1 large banana
- C. 1 medium potato
- D. 1 cup cooked broccoli
Correct Answer: D
Rationale: The correct answer is D: 1 cup cooked broccoli. Broccoli is a good source of calcium, with approximately 43 mg per cup. This is important for pregnant women, especially those following a vegan diet, as they need to ensure adequate calcium intake for fetal development and bone health. Avocado (choice A), banana (choice B), and potato (choice C) are not significant sources of calcium compared to broccoli. Avocado and banana are low in calcium, while potatoes have even less. Thus, broccoli is the best option for the client to meet her calcium needs.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn’s temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. This is because lotions or ointments can interfere with the effectiveness of phototherapy by blocking the light from reaching the skin. Dressing the newborn in lightweight clothing (Choice A) is important to maximize skin exposure to the light. Keeping the newborn supine throughout treatment (Choice C) is not directly related to the effectiveness of phototherapy. Measuring the newborn's temperature every 8 hours (Choice D) is important but not specifically related to phototherapy.