Nokea
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
- A. Vomiting
- B. Hypertension
- C. Epigastric pain
- D. Contractions
Correct Answer: D
Rationale: Contractions can indicate preterm labor, a potential complication following amniocentesis. Vomiting, hypertension, and epigastric pain are less directly related to the procedure.
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A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I should increase my protein intake to 60 grams each day."
- B. "I should drink 2 liters of water each day."
- C. "I should increase my overall daily caloric intake by 300 calories."
- D. "I should take 600 micrograms of folic acid each day."
Correct Answer: A
Rationale: The correct answer is A because protein is essential for fetal development and increasing protein intake to 60 grams per day is recommended during pregnancy for optimal growth. Adequate protein intake helps in the formation of new tissues and cells.
Choice B is incorrect because while staying hydrated is important during pregnancy, the specific amount of 2 liters per day is not a standard recommendation and may vary depending on individual needs.
Choice C is incorrect as increasing overall daily caloric intake by 300 calories is a general guideline, not specific to the client's gestational age.
Choice D is incorrect as while folic acid is crucial during pregnancy to prevent birth defects, the recommended daily intake is usually 400-800 micrograms, so 600 micrograms is within the range but not the best answer.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome (NAS) occurs in newborns exposed to addictive substances in utero. The newborn may exhibit symptoms such as excessive crying due to neurologic irritability. Diminished deep tendon reflexes (A) are not typically associated with NAS. Decreased muscle tone (C) is not a common finding in NAS; infants may actually have increased muscle tone. An absent Moro reflex (D) is not a typical finding in NAS, as hyperreflexia is more common.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can lead to facial nerve injury, resulting in facial palsy. This occurs due to pressure exerted by the forceps on the baby's face during delivery. The other choices are incorrect because: A) Polycythemia is not directly related to forceps-assisted birth. B) Hypoglycemia is more commonly associated with maternal diabetes or prematurity. C) Bronchopulmonary dysplasia is a lung condition seen in premature infants requiring prolonged mechanical ventilation. In summary, facial palsy is the most likely complication of forceps-assisted birth due to potential nerve injury, while the other choices are less directly linked to this birthing method.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority because it assesses the well-being of the fetus immediately after the client's water breaks, ensuring timely detection of any fetal distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can wait until after FHR monitoring. Assessing the fluid (B) may be important but not as urgent as monitoring the FHR.
What is the primary ethical principle guiding nursing practice in maternal and newborn healthcare?
- A. Autonomy
- B. Non-maleficence
- C. Beneficence
- D. Justice
Correct Answer: C
Rationale: The correct answer is C: Beneficence. In maternal and newborn healthcare, beneficence is the primary ethical principle guiding nursing practice. This principle emphasizes the nurse's duty to promote the well-being and best interests of both the mother and the newborn. Nurses must act in a way that benefits their patients and ensures their safety and health. Autonomy (A) focuses on respecting the patient's right to make their own decisions, which is important but not the primary principle in this context. Non-maleficence (B) involves avoiding harm, which is essential but not the primary guiding principle here. Justice (D) pertains to fairness in healthcare access and resource allocation, which is also crucial but not the primary ethical principle for maternal and newborn healthcare.