A nurse is reviewing the laboratory results for a newborn 12 hours old. Which of the following is an expected findings.
- A. Glucose 40mg/dl
- B. WBC 6000
- C. Hemoglobin 12
- D. Platelets 80000
Correct Answer: A
Rationale: The correct answer is A: Glucose 40mg/dl. In newborns, normal glucose levels range from 40-60mg/dl. This level is expected to be lower in the immediate postnatal period due to the transition from placental to independent glucose regulation. WBC count of 6000 is within normal range. Hemoglobin at 12 is normal for a newborn. Platelets of 80000 are low and could indicate a potential issue, such as thrombocytopenia, which would require further investigation.
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A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Negele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
- A. December 15
- B. October 30
- C. January 15
- D. Nov 30
Correct Answer: A
Rationale: To calculate the estimated due date using Negele's rule, we add 7 days to the first day of the last menstrual period, subtract 3 months, and then add a year. March 8 + 7 days = March 15. Subtracting 3 months gives us December 15. Adding a year gives the estimated due date as December 15. This is the correct answer as it follows the standard calculation method. Other choices are incorrect as they do not follow the correct formula or have errors in calculation.
A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy. This of the following statements by the client indicates an understanding of the teaching.
- A. “I will count baby’s lacks every other day.
- B. “I will alternate the arm use to check my blood pressure
- C. I will check my urine for protein daily
- D. I will consume 50 grams of protein daily
Correct Answer: C
Rationale: The correct answer is C: "I will check my urine for protein daily." This is the correct answer because monitoring urine for protein is crucial in managing preeclampsia. Proteinuria is a key marker for worsening preeclampsia as it indicates kidney damage. By checking urine daily, the client can detect early signs of deterioration and seek medical help promptly.
Answers A, B, and D are incorrect because they do not directly relate to monitoring preeclampsia. Counting baby's kicks (A) and alternating arm use for blood pressure checks (B) are important but not as critical as monitoring proteinuria. Consuming 50 grams of protein daily (D) is beneficial for overall health during pregnancy but does not specifically address the management of preeclampsia.
A nurse is planning care for a client who is pregnant and has HIV.
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin-to-skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin-to-skin contact. This is because bathing the newborn before skin-to-skin contact helps reduce the risk of HIV transmission from mother to baby. HIV can be present in maternal blood and other fluids, and washing the newborn can decrease the viral load on the baby's skin. Initiating skin-to-skin contact without bathing first may increase the risk of transmission.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to baby. Choice C is incorrect as stopping antiretroviral medication can be harmful to both the mother and the baby's health. Choice D is incorrect as pneumococcal immunization is not recommended within 4 hours following birth and is not directly related to HIV transmission prevention.
A nurse is planning care for a client who is scheduled for a cesarian birth. Which of the following interventions should the nurse include in the plan of care?
- A. Instruct the client not to eat after midnight the night before
- B. Perform a surgical time out
- C. Shave the client’s abdomen at the preoperative visit
- D. Secure the clients hair to their scalp with metal hair pins
Correct Answer: B
Rationale: The correct answer is B: Perform a surgical time out. This step is crucial before any surgical procedure, including a cesarean birth, to ensure patient safety. During the time out, the surgical team verifies the patient's identity, correct procedure, correct site, and other essential details to prevent errors. In contrast, choice A is outdated practice as current guidelines allow clear fluids up to a few hours before surgery. Choice C is unnecessary and can increase the risk of infection. Choice D is incorrect as metal hairpins are not recommended due to the risk of injury and interference with surgical equipment.
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.