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An infant of a diabetic mother, 40 weeks’ gestation, weight 4,500 grams, has just been admitted to the neonatal nursery. The neonatal intensive care nurse will monitor this baby for which of the following? Select all that apply.
- A. Hyperreflexia.
- B. Hypoglycemia.
- C. Respiratory distress.
- D. Opisthotonus.
Correct Answer: C
Rationale: Infants of diabetic mothers are at risk for hypoglycemia due to maternal hyperglycemia and respiratory distress due to delayed lung maturity.
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Which of the following features would the nurse expect to be absent in an 8-week-gestation embryo?
- A. Four-chambered heart.
- B. Fingers and toes.
- C. Fully formed genitalia.
- D. Facial features.
Correct Answer: C
Rationale: At 8 weeks, the embryo’s genitalia are not fully formed, though other features like the heart and facial structures are developing.
The nurse is working with a pregnant woman who states that she is a vegan. Which of the following actions by the nurse is appropriate?
- A. Advise the mother that she must eat some animal protein during her pregnancy.
- B. Refer the woman to a nutritionist for diet counseling.
- C. Remind the mother that cashews and coconut are excellent sources of calcium.
- D. Congratulate the woman on agreeing to eat eggs and milk.
Correct Answer: B
Rationale: A nutritionist can help ensure the vegan mother receives adequate nutrients, such as B12, iron, and protein, during pregnancy.
The nurse is discussing the purpose of the physical examination with a patient at the first prenatal visit. What information does the nurse include in the discussion?
- A. The physical exam helps to confirm the patient's current health.
- B. The physical exam determines nutritional risk factors.
- C. The physical exam confirms the diagnosis of STIs.
- D. The physical exam includes urinalysis.
Correct Answer: A
Rationale: The correct answer is A because the physical exam at the first prenatal visit aims to confirm the patient's current health status, assess baseline health indicators, and identify any potential risks or issues that may affect the pregnancy. This information is crucial for developing a personalized care plan for the patient and ensuring a healthy pregnancy outcome.
Choice B is incorrect because determining nutritional risk factors typically involves assessing dietary habits, weight, and specific nutrient deficiencies, which are not solely addressed through a physical exam.
Choice C is incorrect as confirming the diagnosis of STIs would require specific testing and not solely rely on a physical examination.
Choice D is incorrect because while urinalysis may be part of the physical exam, its primary purpose is not solely to include urinalysis but to comprehensively evaluate the patient's overall health.
A gravida 1 patient at 32 weeks of gestation reports that she has severe lower back pain. What should the nurse's assessment include?
- A. Palpation of the lumbar spine
- B. Exercise pattern and duration
- C. Observation of posture and body mechanics
- D. Ability to sleep for at least 6 hours uninterrupted
Correct Answer: C
Rationale: The correct answer is C. Observation of posture and body mechanics is essential in assessing lower back pain in a pregnant patient to identify any potential causes related to the growing uterus and changes in body mechanics. Palpation of the lumbar spine (Choice A) may provide some information but does not address the underlying issue. Exercise pattern and duration (Choice B) are important but not the priority in this scenario. Ability to sleep for at least 6 hours uninterrupted (Choice D) is not directly related to assessing lower back pain.
Which technique would provide the best pain relief for a pregnant woman with an occiput posterior position?
- A. Neuromuscular disassociation
- B. Effleurage
- C. Psychoprophylaxis
- D. Sacral pressure
Correct Answer: D
Rationale: The correct answer is D: Sacral pressure. This technique involves applying pressure to the sacrum to alleviate back pain associated with an occiput posterior position. The pressure helps relieve tension and discomfort in the lower back, providing effective pain relief for the pregnant woman.
A: Neuromuscular disassociation is not specific to addressing the pain associated with the occiput posterior position in pregnancy.
B: Effleurage is a gentle massage technique that may provide some relaxation but may not be as effective as sacral pressure for pain relief in this specific scenario.
C: Psychoprophylaxis is a method of preparing for childbirth through education and relaxation techniques, but it may not directly target the pain caused by the occiput posterior position.
In summary, sacral pressure is the most appropriate technique as it directly addresses the specific pain associated with the occiput posterior position in pregnancy, unlike the other choices.