Nokea
Pregnant woman educated about placental hormones
After teaching a pregnant woman about the hormones produced by the placenta, the nurse determines that the teaching was successful when the woman identifies which hormone produced as being the basis for pregnancy tests?
- A. Human placental lactogen (hPL).
- B. Estrogen (estriol).
- C. Progesterone (progestin).
- D. Human chorionic gonadotropin (hCG).
Correct Answer: D
Rationale: Human chorionic gonadotropin (hCG) is produced by the fertilized egg and detected in pregnancy tests, indicating fertilization and implantation.
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Newborn immediately after birth
The priority nursing care of the newborn immediately after birth includes all except:
- A. Support thermoregulation.
- B. Identify the infant.
- C. Promote normal respirations.
- D. Announcement of the delivery.
Correct Answer: D
Rationale: Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
Client receiving oxytocin (Pitocin) infusion
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
- A. Measuring urinary output.
- B. Evaluating cervical dilation.
- C. Increasing infusion rate every 30 minutes.
- D. Monitoring uterine response.
Correct Answer: D
Rationale: Monitoring uterine response is critical as oxytocin can cause excessive contractions, risking fetal distress, uterine rupture, or placental abruption.
Newborn, 2 days old, lost 6 ounces since birth
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
- A. 10% to 15% of their birth weight.
- B. 20% of their birth weight.
- C. 15% to 18% of their birth weight.
- D. 5% to 10% of their birth weight.
Correct Answer: D
Rationale: 5% to 10% of their birth weight is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight due to insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth.
Newborn, signs of diaphoresis, jitteriness, lethargy
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
- A. Obtain blood glucose by heel stick.
- B. Initiate phototherapy.
- C. Monitor the newborn's blood pressure.
- D. Place the newborn in a radiant warmer.
Correct Answer: A
Rationale: These symptoms suggest hypoglycemia, and obtaining a blood glucose level via heel stick is the priority to confirm and guide treatment.
Early postpartum woman
Which maternal event is abnormal in the early postpartum period?
- A. Lochial color changes from rubra to alba.
- B. Extreme hunger and thirst.
- C. Diuresis and diaphoresis.
- D. Flatulence and constipation.
Correct Answer: B
Rationale: Extreme hunger and thirst may indicate abnormal blood sugar levels or metabolic issues, requiring further evaluation, unlike the other normal postpartum events.