Nokea
A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?
- A. Chromosomal abnormalities
- B. Sex and size of the infant
- C. Lecithin-sphingomyelin ratio
- D. Fetal growth and gestational age.
Correct Answer: D
Rationale: A routine ultrasound at 20 weeks primarily assesses fetal growth and gestational age to ensure proper development.
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After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?
- A. Strawberries
- B. Collard greens.
- C. Whole milk
- D. Yogurt
Correct Answer: A
Rationale: Strawberries provide a moderate amount of folic acid and are suitable given the client's dislike for green leafy vegetables and soy allergy.
The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Cries vigorously when stimulated
- B. A positive Babinski reflex
- C. Heart rate of 220 beats/minute
- D. Flexion of all four extremities
Correct Answer: A
Rationale: Vigorous crying indicates effective breathing and responsiveness, key signs of successful transition to extrauterine life.
The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?
- A. Administer oxygen via facemask.
- B. Turn off the oxytocin infusion
- C. Assess cervical dilatation
- D. Change the client's position
Correct Answer: D
Rationale: Variable decelerations often result from umbilical cord compression. Changing the client's position, such as to a lateral or knee-chest position, is the first step to relieve this.
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonic and weak cry. Based on these findings, which action should the nurse implement?
- A. Document the findings in the record
- B. Obtain a heel stick blood glucose level.
- C. Place a pulse oximeter on the heel.
- D. Swaddle the infant in a warm blanket
Correct Answer: B
Rationale: Jitteriness, hypotonia, and a weak cry suggest possible hypoglycemia, a critical condition requiring immediate blood glucose testing.
A 25-year-old client who had a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for what complication has the highest priority for this client?
- A. Placenta accreta
- B. Hard, painful uterine afterpains.
- C. Postpartum psychosis.
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: Severe postpartum hemorrhage increases the risk of disseminated intravascular coagulation (DIC), a life-threatening condition requiring urgent assessment.