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A primiparous client, who has just delivered a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?
- A. Disappointment in the baby's gender.
- B. Grief over the ending of the pregnancy.
- C. A normal response to the birth.
- D. Indication of postpartum 'blues.'
Correct Answer: C
Rationale: Crying after delivery is a normal emotional response to the intense experience of birth, reflecting joy, relief, or overwhelming emotions. It does not indicate disappointment, grief, or postpartum blues, which typically manifest later.
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The father of a neonate diagnosed with gastroschisis tells the nurse that his wife had planned on breast-feeding the neonate. Which of the following should the nurse include in the preoperative teaching plan about feeding the neonate?
- A. The neonate will remain on nothing-by-mouth (NPO) status until after surgery.
- B. An iron-fortified formula will be given before surgery.
- C. The neonate will need total parenteral nutrition for nourishment.
- D. The mother may breast-feed the neonate before surgery.
Correct Answer: A
Rationale: The neonate must remain NPO before surgery to prevent complications related to the exposed intestines.
A nurse is teaching a client about the lactational amenorrhea method. Which of the following client statements indicates a need for further teaching?
- A. I need to exclusively breastfeed for this method to work.
- B. This method is effective for up to 6 months postpartum.
- C. I can use this method even if my periods have returned.
- D. I must breastfeed on demand, including at night.
Correct Answer: C
Rationale: The lactational amenorrhea method is not effective if periods have returned, as this indicates ovulation may have resumed, requiring further teaching. The other statements are correct.
After a vaginal delivery of a term neonate, the nurse observes that the neonate has one artery and one vein in the umbilical cord. The nurse notifies the pediatrician based on the analysis that this may be indicative of ?
- A. Respiratory anomalies.
- B. Musculoskeletal anomalies.
- C. Cardiovascular anomalies.
- D. Facial anomalies.
Correct Answer: C
Rationale: A single umbilical artery is associated with an increased risk of cardiovascular anomalies, warranting further evaluation.
Soon after admission of a primigravid client at 38 weeks' gestation with severe preeclampsia, the physician orders a continuous intravenous infusion of 5% dextrose in Ringer's solution and 4 g of magnesium sulfate. While the medication is being administered, which of the following assessment findings should the nurse report immediately?
- A. Respiratory rate of 12 breaths/minute.
- B. Patellar reflex of +2.
- C. Blood pressure of 160/88 mm Hg.
- D. Urinary output exceeding intake.
Correct Answer: A
Rationale: A respiratory rate of 12 breaths/minute indicates potential magnesium sulfate toxicity.
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.