Nokea
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.
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A nurse is discussing the contraceptive sponge with a client. Which of the following client statements indicates understanding?
- A. I need to insert the sponge at least 1 hour before intercourse.
- B. The sponge can be left in place for up to 24 hours.
- C. The sponge is more effective after childbirth.
- D. The sponge protects against HIV.
Correct Answer: B
Rationale: The contraceptive sponge can be left in place for up to 24 hours, providing flexibility. It should be inserted just before intercourse (not 1 hour prior), is less effective after childbirth, and does not protect against HIV.
When teaching a primiparous client about the growth and development of the neonate, which of the following should the nurse include as the usual age at which most babies are able to drink from a cup independently?
- A. 5 to 7 months.
- B. 8 to 10 months.
- C. 12 to 14 months.
- D. 15 to 16 months.
Correct Answer: C
Rationale: Most babies can drink from a cup independently by 12-14 months as motor skills develop.
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.
A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following delivery. The nurse determines the client understands principles of infection control to follow when the client says:
- A. I must use barrier isolation.
- B. I must wear a gown and gloves.
- C. I must use individual client care equipment.
- D. I must practice frequent hand washing.
Correct Answer: D
Rationale: Frequent hand washing is the most effective infection control measure for a respiratory tract infection.
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.