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An African American woman noticed bruises on a newborn girl's buttocks, and she asks the nurse who spanked the baby? The nurse responds
- A. Mongolian spots
- B. Ecchymosis
- C. Birth trauma
- D. Petechiae
Correct Answer: A
Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.
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A client at 36 weeks' gestation reports frequent urination and lower back pain. What should the nurse assess for?
- A. Preterm labor.
- B. Urinary tract infection.
- C. Normal third-trimester changes.
- D. Preeclampsia.
Correct Answer: A
Rationale: Frequent urination and back pain at 36 weeks may indicate preterm labor and require further assessment.
A laboring patient's obstetrician suggested an amniotomy as a method for inducing the labor. Which assessment must be made before the amniotomy is performed?
- A. Fetal presentation, position, and station
- B. Estimate fetal birth weight
- C. Maternal temperature, BP, pulse
- D. Biparietal diameter
Correct Answer: A
Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.
A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.
Which action by the nurse prevents infection in the labor and birth area?
- A. Keeping under pad and linen as dry as possible
- B. Performing vaginal exam q hour while client in active area
- C. Cleaning secretion from vaginal area using back to front
- D. Using clean technique for all procedures
Correct Answer: D
Rationale: Using clean technique for all procedures helps prevent infection in the labor and birth area. A clean technique involves maintaining cleanliness and limiting contamination during procedures. This includes proper hand hygiene, use of clean gloves, and ensuring that equipment and supplies are kept clean and sterile as needed. By adhering to clean techniques, the nurse reduces the risk of introducing harmful microorganisms into the labor and birth area, ultimately reducing the chances of infection for both the mother and baby. It is important for the nurse to practice proper infection control measures to provide a safe environment for labor and birth.
What teaching is most important for a mother with a newborn receiving phototherapy?
- A. Ensure the newborn wears protective eyewear
- B. Increase the newborn's fluid intake
- C. Turn the newborn frequently to prevent pressure sores
- D. Monitor bilirubin levels every 8 hours
Correct Answer: A
Rationale: Protective eyewear prevents retinal damage during phototherapy.