Nokea
A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.
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Which complication of adolescent pregnancy should the nurse plan to monitor?
- A. Anemia
- B. Placenta previa
- C. Abruptio placenta
- D. Incompetent cervix
Correct Answer: D
Rationale: Incompetent cervix, also known as cervical insufficiency, is a condition where the cervix begins to dilate and efface prematurely due to weak cervical tissue. This can lead to late miscarriage or preterm birth. Adolescent mothers are at a higher risk for this complication due to their immature reproductive systems. Therefore, the nurse should plan to monitor for signs and symptoms of incompetent cervix in adolescent pregnant clients to prevent adverse maternal and fetal outcomes. Anemia, placenta previa, and abruptio placenta are other potential complications of pregnancy, but they are not specifically associated with adolescent pregnancy.
During which stage of the menstrual cycle does the endometrium layer thicken?
- A. Proliferative phase
- B. Ovulation phase
- C. Luteal phase
- D. Secretory phase
Correct Answer: D
Rationale: The endometrium layer thickens during the secretory phase of the menstrual cycle. This phase occurs after ovulation and is characterized by the endometrium preparing for possible implantation of a fertilized egg by further thickening and becoming more vascularized. If pregnancy does not occur, the thickened endometrial lining will be shed during menstruation. The secretory phase is under the control of the hormone progesterone, which is produced by the corpus luteum formed in the ovary after ovulation.
Which lifestyle factor is associated with an increased risk of developing breast cancer?
- A. regular physical activity
- B. moderate alcohol consumption
- C. maintaining a healthy weight after menopause
- D. excessive alcohol consumption
Correct Answer: D
Rationale:
A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor
- A. Cervical dilation
- B. Report of pain above the umbilicus
- C. Brownish vaginal discharge
- D. Amniotic fluid in the vaginal vault
Correct Answer: A
Rationale: Cervical dilation is a key physiological change that confirms labor has begun. During the late stages of pregnancy, the cervix starts to soften, thin out (efface), and open up (dilate) in preparation for childbirth. Therefore, cervical dilation is a critical finding that indicates the onset of labor. Pain above the umbilicus, brownish vaginal discharge, and amniotic fluid in the vaginal vault are not definitive signs of labor and do not confirm the initiation of the labor process.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."