Nokea
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. In a nonstress test, the client is required to monitor fetal movements and press a button each time they are felt. This helps assess fetal well-being by measuring the heart rate in response to movement. This action is essential for the accurate interpretation of the test results. Maintaining the client NPO (A) is not necessary for this procedure. Placing the client in a supine position (B) can lead to decreased blood flow to the fetus. Instructing the client to massage the abdomen (C) may interfere with the natural fetal movements being monitored. Therefore, the correct action is to have the client press the button when fetal movement is detected to ensure an accurate assessment of fetal well-being.
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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: Verifying the newborn's identification is the first priority to ensure that the correct newborn is receiving care, especially in a busy nursery setting.
What is the recommended method of feeding for a full-term newborn who is not at risk for hypoglycemia?
- A. Breastfeeding
- B. Formula feeding
- C. Tube feeding
- D. All of the above
Correct Answer: A
Rationale: Breastfeeding is the recommended method of feeding for full-term newborns who are not at risk for hypoglycemia.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Pressing the handheld button when the client feels fetal movement helps to correlate fetal movements with changes in the fetal heart rate, which is the purpose of the nonstress test.
A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identity as a manifestation of Increased risk for child abuse?
- A. I want to meet other parents to see if they are going through the same things.
- B. I try to respond to the baby quickly so she doesn't cry very long.
- C. I think the baby should be sleeping through the night by now.
- D. I have several friends who come by to help out with the baby.
Correct Answer: C
Rationale: Expecting a newborn to sleep through the night is unrealistic and may indicate frustration or lack of understanding, which are risk factors for child abuse. Other statements reflect normal parental concerns or support systems.
Which of the following is a legal issue related to maternal and newborn healthcare?
- A. Informed consent
- B. Patient confidentiality
- C. Malpractice
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. In maternal and newborn healthcare, legal issues encompass informed consent (A), as healthcare providers must ensure patients understand risks and benefits before treatment. Patient confidentiality (B) is crucial to protect sensitive health information. Malpractice (C) involves negligence or misconduct by healthcare providers that result in harm. All three options are interconnected and essential legal considerations in maternal and newborn healthcare to ensure quality care and patient rights are upheld.