Nokea
At the first prenatal visit, the patient informs the nurse that the first day of her last menstrual period (LMP) was February 18, 2024. Using Naegle's Rule, calculate the patient's EDD.
- A. 11-Nov-24
- B. 11-Nov-25
- C. 25-Nov-24
- D. 25-Nov-25
Correct Answer: C
Rationale: The correct answer is C: 25-Nov-24. Naegle's Rule is to add 7 days to the first day of the last menstrual period (LMP), then subtract 3 months, and finally add 1 year. In this case, LMP was February 18, 2024. Adding 7 days gives February 25, 2024. Subtracting 3 months gives November 25, 2024. Adding 1 year gives the estimated due date (EDD) of November 25, 2024. Choices A, B, and D are incorrect because they do not follow the correct calculation steps of Naegle's Rule.
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The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?
- A. Complaints of severe back pain.
- B. Rapid descent and effacement.
- C. Irregular and hypotonic contractions.
- D. Rectal pressure with bloody show.
Correct Answer: A
Rationale: The LOP (left occiput posterior) position often causes back pain due to the fetal head pressing against the mother’s sacrum.
A G1 P0000 gravida, whose labor was uneventful, delivered 1 minute ago. The baby’s Apgar score at this time is 3. Which of the following actions is appropriate for the nurse to make?
- A. Administer ophthalmic prophylaxis.
- B. Place the baby on the abdomen of the mother.
- C. Obtain assistance for neonatal resuscitation.
- D. Repeat the score to confirm its accuracy.
Correct Answer: C
Rationale: An Apgar score of 3 indicates the baby is in distress and requires immediate neonatal resuscitation.
The nurse's role in diagnostic testing is to provide which of the following?
- A. Advice to the couple
- B. Information about the tests
- C. Reassurance about fetal safety
- D. Assistance with decision making
Correct Answer: B
Rationale: The correct answer is B: Information about the tests. The nurse's role in diagnostic testing is to educate the couple about the purpose, procedure, risks, and benefits of the tests. This empowers them to make informed decisions. Providing advice (A) may be beyond the nurse's scope. Reassurance about fetal safety (C) is important but not the primary role. While the nurse may assist with decision-making (D), the key focus should be on providing comprehensive information.
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.
A couple has decided not to circumcise their son. Based on this decision, which of the following instructions should the nurse include in the parent teaching?
- A. The couple should check their son’s temperature every evening because he will be high risk for urinary tract infections.
- B. The couple should fully retract the foreskin to assess for the presence of exudate every morning.
- C. The pediatrician will observe the baby void during each well-baby examination to assess for a phimosis.
- D. The prepuce should be cleansed with soap and water every day during the baby’s sponge bath.
Correct Answer: D
Rationale: Proper hygiene, including cleaning the uncircumcised penis with soap and water, helps prevent infections.