Nokea
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
- A. “There is no need to worry about that. Most forms of hearing loss are not inherited.”
- B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
- C. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”
- D. “Look at how she looks at you when you speak. That’s a good sign.”
Correct Answer: B
Rationale: Rationale: Choice B is correct because routine hearing screenings for newborns are a standard practice to assess hearing ability. This screening is important for early detection and intervention if hearing loss is present. The other choices are incorrect because: A dismisses the client's concerns and provides inaccurate information, C is not a reliable method to assess hearing, and D, while somewhat accurate, does not provide a definitive assessment like a hearing screening would.
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A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
- A. Drying the newborn’s skin thoroughly.
- B. Preventing air drafts.
- C. Placing the newborn on a warm surface.
- D. Maintaining ambient room temperature at 24°C (75.2°F).
Correct Answer: A
Rationale: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (B) and placing the newborn on a warm surface (C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (D) is important for thermoregulation but does not directly address evaporative heat loss.
A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?
- A. It assists in identifying the location of the placenta and fetus.
- B. It is useful for estimating fetal age.
- C. This is a screening tool for spina bifida.
- D. This will determine if there is more than one fetus.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Prior to amniocentesis, an ultrasound is done to identify the location of the placenta and fetus. This is crucial to ensure the safety of the procedure. It helps in determining the best site for needle insertion to avoid harming the fetus or placenta. Additionally, it allows for visualization of any abnormalities that could affect the amniocentesis procedure.
Summary of other choices:
B: Estimating fetal age is not the primary purpose of the ultrasound before amniocentesis.
C: Screening for spina bifida is usually done through other specific tests, not the ultrasound before amniocentesis.
D: Determining if there is more than one fetus is not the main goal of the ultrasound before amniocentesis.
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?
- A. Turning on the apnea#nbsp;apnea and cardiorespiratory monitor.
- B. Connecting the resuscitation bag to oxygen.
- C. Setting up the radiant warmer control temperature at 36.4°C (97.5°F).
- D. Preparing for the insertion of an intravenous (IV) line with D5W.
Correct Answer: B
Rationale: The correct answer is B: Connecting the resuscitation bag to oxygen. This intervention is the priority because the infant has low Apgar scores, indicating poor oxygenation and respiratory effort. Providing oxygen through the resuscitation bag will help improve oxygenation and support the infant's breathing, which is crucial in the immediate postnatal period.
Turning on the apnea and cardiorespiratory monitor (Choice A) may be important for continuous monitoring but addressing the oxygenation issue takes precedence. Setting up the radiant warmer control temperature (Choice C) is important for maintaining the infant's body temperature but not the immediate priority. Preparing for IV insertion with D5W (Choice D) is not necessary at this moment as the priority is to address the respiratory distress.
A nurse is caring for a client who is postpartum and finds the fundus slightly displaced to the right. Based on these findings, which of the following actions should the nurse take?
- A. Encourage the client to move to the left lateral position.
- B. Encourage the client to perform Kegel exercises.
- C. Assist the client to the bathroom to void.
- D. Ask the client to rate her pain.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to the bathroom to void. This action helps to empty the bladder, which can reduce uterine displacement. A full bladder can push the uterus to one side. Moving the client to the left lateral position (choice A) may not address the underlying issue of a full bladder. Kegel exercises (choice B) are not directly related to fundal displacement. Asking the client to rate her pain (choice D) is not relevant to the situation at hand.
A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?
- A. Rapid decline in human chorionic gonadotropin (hCG) levels
- B. Irregular fetal heart rate
- C. Excessive uterine enlargement
- D. Profuse, clear vaginal discharge
Correct Answer: C
Rationale: The correct answer is C: Excessive uterine enlargement. A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal growth of placental tissue in the uterus, leading to excessive uterine enlargement. This condition results in the absence of a viable fetus and can cause symptoms such as vaginal bleeding, severe nausea, and hypertension. The other choices are incorrect because: A) Rapid decline in hCG levels is not a typical finding in a hydatidiform mole, as hCG levels are usually elevated. B) Irregular fetal heart rate is not applicable in this case since there is no viable fetus. D) Profuse, clear vaginal discharge is not a characteristic symptom of a hydatidiform mole. E, F, and G are not provided as options.