Nokea
A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery?
- A. Cephalopelvic disproportion and hypothermia
- B. Asphyxia and meconium aspiration
- C. Intraventricular hemorrhage and dry,cracked skin
- D. Hyperbilirubinemia and hypocalcemia
Correct Answer: B
Rationale: The correct answer is B: Asphyxia and meconium aspiration. At 42 weeks gestation, the risk of perinatal asphyxia increases due to decreased placental function. Meconium aspiration can occur if the fetus passes stool in utero, leading to respiratory distress. The other choices are not directly related to postterm pregnancy complications. Cephalopelvic disproportion and hypothermia (Choice A) are not specific to postterm pregnancy. Intraventricular hemorrhage and dry, cracked skin (Choice C) are not commonly associated with postterm pregnancies. Hyperbilirubinemia and hypocalcemia (Choice D) are more likely to occur after birth and are not directly related to being postterm.
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A nurse is discussing nutrition with an adolescent who is pregnant.
- A. "I told my daughter that any calories ingested are a source of energy and nutrition."'
- B. "I try to provide foods with an increased amount of calcium,protein and iron."'
- C. "I encourage between-meal snacks that are complex carbohydrates and fruits."'
- D. "I have planned meals and snacks for additional calories in the second and third trimester."'
Correct Answer: A
Rationale: Step 1: A is correct because it emphasizes the importance of calorie intake for energy and nutrition during pregnancy.
Step 2: Adolescents have higher calorie needs during pregnancy, making this advice crucial.
Step 3: B focuses on specific nutrients but doesn't address overall calorie intake.
Step 4: C mentions healthy snacks but doesn't emphasize the importance of calories.
Step 5: D mentions additional calories but lacks the focus on all calories being essential.
Step 6: A provides a comprehensive approach to nutrition during pregnancy, making it the correct choice.
A nurse is caring for a 4-month-old infant with thrush (candidiasis) who is breastfed.
- A. "Administer the prescribed nystatin (Mycostatin) for 2 to 3 days after the lesions disappear."'
- B. "Place the infant on a soy-based formula to supplement breastfeeding until thrush is resolved."'
- C. "Discontinue breastfeeding and resume 48 hr after the last lesion disappears."'
- D. "Scrape off the white patches of thrush from the oral mucous membrane with a tongue depressor."'
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Nystatin is an antifungal medication commonly used to treat thrush in infants. It is safe for infants and effective against Candida. The treatment should be continued for 2 to 3 days after the lesions disappear to ensure complete eradication of the infection. Discontinuing the medication prematurely can lead to a recurrence of thrush.
Summary of other choices:
B: Switching to a soy-based formula is unnecessary and does not address the thrush infection directly.
C: Discontinuing breastfeeding is not necessary and can disrupt the infant's feeding routine.
D: Scraping off the white patches can cause trauma to the oral mucosa and should be avoided.
Which method of temperature regulation would safely and effectively prevent cold stress in a newly delivered infant?
- A. Wrap the baby loosely with a blanket.
- B. Be sure the baby's feet are covered.
- C. Cover the baby's head with a hat.
- D. Position the baby on a heating pad.
Correct Answer: C
Rationale: The correct answer is C: Cover the baby's head with a hat. Infants lose a significant amount of heat through their heads, so covering the head with a hat helps prevent heat loss and cold stress. Option A does not provide enough insulation to prevent cold stress. Option B only addresses the feet, while the head is a major heat loss area. Option D poses a risk of overheating and burns.
Which of the following emotional manifestations demonstrates an improvement in a 7-month-old infant diagnosed with nonorganic failure to thrive?
- A. Infant has no fear of strangers.
- B. Infant scans environment with wide-eyed gaze.
- C. Infant is passive and sleeps well.
- D. Infant likes to be held and touched.
Correct Answer: D
Rationale: The correct answer is D: Infant likes to be held and touched. This demonstrates an improvement in the infant's emotional well-being as it shows an attachment behavior, indicating a sense of security and trust. Infants with nonorganic failure to thrive often exhibit social withdrawal and disinterest in physical contact. Choice A is incorrect as it describes a lack of stranger anxiety, which is not necessarily indicative of improvement in this context. Choice B is incorrect as a wide-eyed gaze could indicate vigilance or anxiety rather than positive emotional development. Choice C is incorrect as passivity and good sleep are not specific indicators of emotional improvement. In summary, choice D is the correct answer as it reflects positive emotional progress in the infant's attachment and responsiveness to touch.
A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestation for which the nurse should monitor?
- A. Anaphylaxis
- B. Cerebral edema
- C. Impaired coagulation
- D. Hypervolemia
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. In Reye syndrome, cerebral edema is the most serious manifestation due to increased intracranial pressure, potentially leading to brain damage or death. Anaphylaxis (A) is not typically associated with Reye syndrome. Impaired coagulation (C) can occur but is not as immediately life-threatening as cerebral edema. Hypervolemia (D) is a possible complication but not as critical as cerebral edema in Reye syndrome.