Nokea
After instructing a mother about normal reflexes of term neonates, the nurse determines that the mother understands the instructions when she describes the tonic neck reflex as occurring when the neonate does which of the following?
- A. Steps briskly when held upright near a firm, hard surface.
- B. Pulls both arms and does not move the chin beyond the point of the elbows.
- C. Turns head to the left, extends left extremities, and flexes right extremities.
- D. Extends and abducts the arms and legs with the toes fanning open.
Correct Answer: C
Rationale: The tonic neck reflex involves the neonate turning the head to one side, extending the extremities on that side, and flexing the opposite side.
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The nurse in a postpartum couplet room is making rounds prior to ending the shift. Which of the following indicate that the safety needs of the clients have been met?
- A. Infant lying on abdomen.
- B. Security tags in place.
- C. Identification system on mother and infant.
- D. Bulb syringe within sight.
- E. Someone in room able to care for infant.
- F. Infant in the mother's bed, side rails up.
- G. Infant in the mother's arms, both asleep.
Correct Answer: B,C,D,E
Rationale: Safety needs are met with security tags, identification systems, a bulb syringe for suctioning, and someone present to care for the infant.
A primigravid client with class II heart disease who is visiting the clinic at 8 weeks' gestation tells the nurse that she has been maintaining a low-sodium, 1,800-calorie diet. Which of the following instructions should the nurse give the client?
- A. Avoid folic acid supplements to prevent megaloblastic anemia.
- B. Severely restrict sodium intake throughout the pregnancy.
- C. Take iron supplements with milk to enhance absorption.
- D. Increase caloric intake to 2,200 calories daily to promote fetal growth.
Correct Answer: D
Rationale: Increased caloric intake supports fetal growth without compromising maternal health.
An adolescent primiparous client at 24 hours postpartum tells the nurse that she and her baby will be living with her boyfriend's parents so that she can finish high school and go on to college. The client's boyfriend and parents have been supportive of the client and neonate. Which of the following is an appropriate nursing diagnosis at this time?
- A. Anxiety related to return to high school and peer pressure.
- B. Ineffective coping related to inability to view motherhood realistically.
- C. Readiness for enhanced family coping, related to the addition of a new family member.
- D. Deficient knowledge related to the financial and emotional costs of childrearing.
Correct Answer: C
Rationale: The supportive environment suggests readiness for enhanced family coping, which is appropriate given the positive family dynamics.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V. for fluid support. To increase safety prior to hanging new I.V. fluids for a neonate, the nurse should:
- A. Check the neonate's weight.
- B. Determine if the neonate has adequate urine output.
- C. Determine the neonate's glucose level.
- D. Double-check the fluids and physician's order with another nurse.
Correct Answer: D
Rationale: Double-checking the fluids and physician's order with another nurse ensures accuracy and safety, reducing the risk of medication or fluid errors.