Nokea
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Mothers will receive prophylactic treatment with acyclovir prior to delivery.
- B. Transmission can occur via the saliva and urine of the newborn.
- C. Lesions are visible on the mother’s genitalia.
- D. This infection requires that airborne precautions be initiated for the newborn.
Correct Answer: B
Rationale: The correct answer is B: Transmission can occur via the saliva and urine of the newborn. This is because cytomegalovirus (CMV) is commonly spread through bodily fluids like saliva, urine, and breast milk. It is important for the nurse manager to emphasize this point to the newly licensed nurses to highlight the potential routes of transmission.
Choice A is incorrect because acyclovir is not used for the treatment of CMV; it is used for herpes simplex virus infections. Choice C is incorrect because CMV typically does not present with visible lesions on the mother's genitalia. Choice D is incorrect because CMV is not transmitted through airborne routes, so airborne precautions are not necessary. It is important to focus on educating about the correct modes of transmission to prevent the spread of CMV.
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A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted births can put pressure on the baby's face, leading to facial nerve injury and subsequent facial palsy. This can result in weakness or paralysis of facial muscles. Polycythemia (choice A) is not typically associated with forceps-assisted births. Hypoglycemia (choice B) may occur in newborns for various reasons, but it is not directly related to the birth method. Bronchopulmonary dysplasia (choice C) is a lung condition usually seen in premature infants, not specifically linked to forceps deliveries. In summary, facial palsy is the most likely complication of forceps-assisted births due to the pressure exerted on the baby's face during the delivery process.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C - "I will continue taking my insulin if I experience nausea and vomiting."
Rationale: Nausea and vomiting can lead to decreased food intake, which may cause a drop in blood glucose levels. Continuing to take insulin as prescribed is crucial to prevent hypoglycemia and maintain stable blood glucose levels for both the mother and the baby. This demonstrates the client's understanding of the importance of insulin therapy during pregnancy.
Summary of other choices:
A: Increasing insulin doses during the first trimester is not recommended without healthcare provider guidance as insulin needs may vary.
B: Exercising with blood glucose levels of 250 or greater can be dangerous and may lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes, which is not recommended for diabetes management during pregnancy.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate
- B. Chin quivering
- C. Pinpoint pupils
- D. Slowed respirations
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Chin quivering is a common sign of pain in newborns. It indicates discomfort and distress. Decreased heart rate (choice A), pinpoint pupils (choice C), and slowed respirations (choice D) are not typical signs of pain in newborns. Decreased heart rate may indicate relaxation, pinpoint pupils may suggest neurological issues, and slowed respirations may be a response to other factors. Therefore, the most appropriate finding indicating pain in this scenario is chin quivering.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck at birth. This can cause pressure on the baby's blood vessels, leading to tiny red or purple spots on the face called petechiae. This finding indicates possible trauma during delivery. Telangiectatic nevi (choice A) are not typically associated with nuchal cords. Periauricular papillomas (choice C) are benign growths near the ear and are unrelated to nuchal cords. Erythema toxicum (choice D) is a common newborn rash that is not specifically linked to nuchal cords.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL)
- B. A client who is at 34 weeks of gestation and reports epigastric pain
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL)
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria
Correct Answer: B
Rationale: The correct answer is B: A client who is at 34 weeks of gestation and reports epigastric pain. This client should be identified as the priority because epigastric pain in pregnancy can be a sign of preeclampsia, a serious condition that requires immediate attention to prevent maternal and fetal complications. Preeclampsia is characterized by high blood pressure and protein in the urine, and it can lead to seizures (eclampsia) if not managed promptly. The other clients have issues that are important but not as urgent as potential preeclampsia. Client A's blood glucose level is elevated but not critically high, Client C's hemoglobin level is slightly low but not acutely life-threatening, and Client D's symptoms of urinary frequency and dysuria are common in late pregnancy and do not indicate a medical emergency.