Nokea
After delivery of a viable neonate, a 20-year-old primiparous client comments to her mother and the nurse about the baby. Which of the following comments would the nurse interpret as a possible sign of potential maternal-infant bonding problems?
- A. He's got my funny-looking ears!'
- B. He's got my mother should give him the first feeding.'
- C. He's a lot bigger than I expected him to be.'
- D. I want to buy him a blue outfit to wear when we get home.'
Correct Answer: B
Rationale: Delegating the first feeding to the grandmother suggests reluctance to engage in early bonding activities, which could indicate bonding issues. Other comments reflect normal observations or positive engagement with the neonate.
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The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
- A. A amount of bilirubin present.
- B. Presence of red blood cells.
- C. Barr body determination.
- D. Lecithin-sphingomyelin (L/S ratio).
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio in amniotic fluid is a key indicator of fetal lung maturity, with a ratio of 2:1 or higher indicating mature lungs. Bilirubin, red blood cells, and Barr body determination are not used for this purpose.
When developing the initial plan of care for a neonate who was born at 41 weeks' gestation, was diagnosed with meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse include:
- A. Care of an umbilical arterial line.
- B. Frequent ultrasound scans.
- C. Orogastric feedings as soon as possible.
- D. Assessment for symptoms of hyperglycemia.
Correct Answer: A
Rationale: Care of an umbilical arterial line is necessary for monitoring blood gases and blood pressure in a neonate on mechanical ventilation.
A primigravid client at 39 weeks' gestation is admitted to the hospital for induction of labor. The physician has ordered prostaglandin E2 gel (Dinoprostone) for the client. Before administering prostaglandin E2 gel to the client, which of the following should the nurse do first?
- A. Assess the frequency of uterine contractions.
- B. Place the client in a side-lying position.
- C. Determine whether the membranes have ruptured.
- D. Prepare the client for an amniotomy.
Correct Answer: A
Rationale: Prostaglandin E2 gel stimulates contractions, so assessing baseline contraction frequency ensures it is safe to administer (e.g., no hyperstimulation). Membrane status and positioning are secondary, and amniotomy is not required.
The nurse is caring for a term neonate who is diagnosed with patent ductus arteriosus. While performing a physical assessment of the neonate, the nurse anticipates that the neonate will exhibit which of the following?
- A. Decreased cardiac output with faint peripheral pulses.
- B. Profound cyanosis over most of the body.
- C. Loud cardiac murmurs through systole and diastole.
- D. Harsh systolic murmurs with a palpable thrill.
Correct Answer: C
Rationale: Patent ductus arteriosus typically causes a loud, continuous cardiac murmur heard through systole and diastole.
A nurse is discussing the contraceptive implant with a client. Which of the following client statements indicates understanding?
- A. The implant is effective for up to 3 years.
- B. The implant requires daily monitoring.
- C. The implant protects against STIs.
- D. The implant is taken orally.
Correct Answer: A
Rationale: The contraceptive implant is effective for up to 3 years, providing long-term contraception. It does not require daily monitoring, protect against STIs, or involve oral administration.