Nokea
A nurse is providing teaching to a client who is 32 weeks pregnant and has a diagnosis of placenta previa. Which of the following instructions should the nurse include?
- A. Limit physical activity
- B. Monitor fetal movements daily
- C. Call the healthcare provider if contractions begin
- D. All of the above
Correct Answer: D
Rationale: Clients with placenta previa are at increased risk for bleeding and preterm labor. They should limit physical activity, monitor fetal movements, and notify their provider if they experience any contractions or signs of labor.
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A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soap and water.
Correct Answer: D
Rationale: The nurse should instruct the parents to wash the penis gently with soap and water daily, but to avoid retracting the foreskin forcefully as it can cause pain and injury.
A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client¢â‚¬â„¢s membranes have ruptured?
- A. Nonstress test
- B. Biophysical profile
- C. Fern test
- D. Amniocentesis
Correct Answer: C
Rationale: The fern test is used to confirm rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid.
A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance. The nurse notes swelling over the newborn's head that crosses the suture line. The nurse should identify the swelling as which of the following findings?
- A. Nevus simplex
- B. Caput succedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: B
Rationale: Caput succedaneum is swelling of the soft tissues of the head that crosses suture lines, often resulting from pressure during delivery, especially with vacuum extraction.
A laboring client's membranes have just ruptured. What is the nurse's next action?
- A. Assess fetal heart rate pattern
- B. Monitor uterine contractions
- C. Administer oxygen
- D. Prepare for delivery
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Administer oral feedings
- B. Measure abdominal girth
- C. Position the newborn prone
- D. Apply warm compresses to the abdomen
Correct Answer: B
Rationale: Measuring abdominal girth is important in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). Other interventions include withholding oral feedings and providing IV fluids or nutrition.