Nokea
A primiparous client expresses concern, asking the nurse why her neonate's eyes are crossed. Which of the following would the nurse include when teaching the mother about neonatal strabismus?
- A. The neonate's eyes are unable to focus on light at this time.
- B. The neonate's eye muscles are not fully developed, causing temporary misalignment.
- C. The condition requires immediate surgical correction.
- D. The neonate's vision is permanently impaired.
Correct Answer: B
Rationale: Neonatal strabismus is common due to immature eye muscle coordination and typically resolves as the muscles develop.
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A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?
- A. Breathe slowly after each contraction.
- B. Avoid the use of analgesics for the labor pain.
- C. Remain in a side-lying position with the head elevated.
- D. Request local anesthesia for vaginal delivery.
Correct Answer: C
Rationale: For class II heart disease, a side-lying position with head elevation reduces cardiac strain by optimizing venous return and oxygenation. Slow breathing is helpful but less specific, avoiding analgesics may increase stress, and local anesthesia is unrelated to cardiac emptying.
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assistance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?
- A. Football hold.
- B. Scissors hold.
- C. Cross-cradle hold.
- D. Cradle hold.
Correct Answer: A
Rationale: The football hold minimizes pressure on the cesarean incision, promoting comfort during breastfeeding.
A 16-year-old client at 34 weeks' gestation, who is being monitored at home with home nursing visits, is diagnosed with mild preeclampsia and has gained 2 lb in the past week. Her current blood pressure is 144/92 mm Hg. Which assessment finding would require further action by the home health nurse?
- A. Occasional headache.
- B. Frequent voiding in large amounts.
- C. 1+ pedal edema.
- D. 3+ protein on urine dipstick.
Correct Answer: D
Rationale: Significant proteinuria suggests worsening preeclampsia.
Which of the following would alert the nurse to suspect that a neonate delivered at 34 weeks' gestation who is currently in an isolette with humidified oxygen and receiving intravenous fluids has developed overhydration?
- A. Hypernatremia.
- B. Polycythemia.
- C. Hypoproteinemia.
- D. Increased urine specific gravity.
Correct Answer: C
Rationale: Hypoproteinemia can result from overhydration, as excess fluid dilutes plasma proteins.
The physician orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose?
- A. Assessment of the fetal hematocrit level.
- B. Increase in the strength of the contractions.
- C. Increase in the fetal heart rate and variability.
- D. Assessment of fetal position.
Correct Answer: C
Rationale: Scalp stimulation is used to assess fetal well-being by eliciting a heart rate acceleration, indicating good oxygenation and variability. It does not assess hematocrit, strengthen contractions, or determine position.