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A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action?
- A. A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations.
- B. Variable decelerations (not late decelerations) are associated with cord compression.
- C. Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions.
- D. Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress.
Correct Answer: D
Rationale: The correct answer is D because late decelerations are associated with uteroplacental insufficiency, resulting in fetal hypoxia. This is a sign of fetal distress, as indicated by the repeated drops in fetal heart rate during contractions. Late decelerations occur after the peak of the contraction, reflecting the delayed recovery of the fetal heart rate due to inadequate oxygen supply from the placenta. This prompts the nurse to notify the physician for further evaluation and intervention to address the underlying cause of fetal distress. Choices A, B, and C are incorrect because they do not accurately describe the characteristics and causes of late decelerations in fetal monitoring.
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Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge?
- A. Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well.
- B. Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms.
- C. In order to stimulate adequate milk production, the breasts should be pumped if the infant is not sucking or eating well, or if the breasts are not fully emptied.
- D. Using soap on the breasts dries the nipples and can cause cracking. The baby should be given a bottle of formula if engorgement occurs.
Correct Answer: C
Rationale: The correct answer is C. It is important to stimulate adequate milk production by pumping if the infant is not sucking or eating well, or if the breasts are not fully emptied. This helps maintain milk supply and prevents engorgement. Option A is incorrect as giving a bottle of formula does not effectively relieve engorgement and can lead to decreased milk production. Option B is incorrect as applying lotion to the nipples is not necessary and may introduce harmful microorganisms. Option D is incorrect as using soap can dry the nipples and lead to cracking, and giving formula is not the recommended solution for engorgement.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client
- B. Instruct the client to schedule an annual pelvic examination
- C. Tell the client she will start medication for HIV immediately after delivery
- D. Report the client’s condition to the local health department
Correct Answer: D
Rationale: Rationale: Reporting the client's HIV positive status to the local health department is crucial for monitoring and preventing the spread of the infection. This action ensures proper follow-up care, contact tracing, and support services for the client and at-risk individuals. Administering penicillin G (choice A) is not indicated for HIV positive status. Instructing the client to schedule a pelvic examination (choice B) is unrelated to the client's HIV status. Delaying HIV medication until after delivery (choice C) can pose risks to both the mother and the baby.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D: "I can give him a tub bath in two days." This statement indicates the need for further clarification because newborns who have undergone circumcision should avoid submerging the area in water until it is fully healed to prevent infection. Tub baths should be avoided until the circumcision site has completely healed, which usually takes about 7-10 days. It is important to keep the area clean and dry during this time to promote healing.
Explanation for other choices:
A: "I should not remove the yellow exudate on the end of the penis." - Correct, as it is normal and part of the healing process.
B: "I will clean his penis with each diaper change." - Correct, as keeping the area clean helps prevent infection.
C: "The circumcision will heal completely within a couple of weeks." - Correct, as the healing process typically takes around 1-2 weeks.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)?
- A. Hemoglobin 10.2 mg/dL and uterine tenderness
- B. Polyuria and weight loss of 3 pounds in the last month
- C. Blood pressure 168/110 and 3+ proteinuria
- D. Hematuria and blood glucose of 160 mg/dL
Correct Answer: C
Rationale: The correct answer is C: Blood pressure 168/110 and 3+ proteinuria. Pregnancy-induced hypertension (PIH) is characterized by high blood pressure (systolic ≥140 mmHg and/or diastolic ≥90 mmHg) and proteinuria. In this case, the blood pressure reading of 168/110 indicates hypertension, and 3+ proteinuria indicates significant protein in the urine, both of which are key diagnostic criteria for PIH.
A: Hemoglobin 10.2 mg/dL and uterine tenderness - These are not specific indicators of PIH.
B: Polyuria and weight loss of 3 pounds in the last month - These symptoms are not typically associated with PIH.
D: Hematuria and blood glucose of 160 mg/dL - Hematuria suggests blood in the urine, which is not a typical finding in PIH, and elevated blood glucose is more indicative of diabetes rather than PIH.
Therefore,