Nokea
A nurse is caring for a client who is in active labor. The nurse notes early decelerations of the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?
- A. Fetal hypoxemia.
- B. Uteroplacental insufficiency.
- C. Cord compression.
- D. Head compression.
Correct Answer: D
Rationale: Early decelerations result from fetal head compression, stimulating the vagus nerve and leading to transient heart rate decreases. This is common during contractions.
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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.
A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby in any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: Checking the identification badge ensures the individual removing the baby is authorized, reducing the risk of abduction. This is a recommended safety practice in hospital settings to protect newborns.
A newborn born two hours ago at 36 weeks gestation has noted findings. Which findings are consistent with neonatal jaundice?
- A. Bruising noted over occiput.
- B. Yellowish hue on sclera and skin blanching.
- C. Transcutaneous bilirubin level 12.5 mg/dL (less than 12 mg/dL).
- D. Phototherapy initiated at 08:45.
Correct Answer: B,C,D
Rationale: Yellowish sclera and blanching skin (B), transcutaneous bilirubin level of 12.5 mg/dL (C), and phototherapy initiation (D) indicate neonatal jaundice from elevated bilirubin levels due to immature hepatic conjugation, requiring monitoring and treatment to prevent kernicterus.
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.
For each of the following potential antihypertensive medications, indicate whether it is recommended or not recommended for use in a pregnant client.
- A. Methyldopa.
- B. Lisinopril.
- C. Labetalol.
- D. Losartan.
- E. Hydralazine.
Correct Answer: A,C,E
Rationale: Methyldopa (A) is safe and effective for pregnancy-induced hypertension. Labetalol (C) is recommended for hypertensive crises with a favorable safety profile. Hydralazine (E) is safe for severe hypertensive emergencies. Lisinopril (B) and Losartan (D) are contraindicated due to teratogenic risks.