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During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?
- A. Vertex
- B. Shoulder
- C. Breech
- D. Mentum
Correct Answer: C
Rationale: During a Leopold maneuver, if the healthcare professional determines that the fetus is in an RSA position, it means the fetal back is on the right side, and the small parts are on the left side, indicating a breech presentation. Therefore, the correct answer is C: Breech. The other choices are incorrect because:
A: Vertex refers to the head-first position.
B: Shoulder presentation would involve feeling the shoulder first during the maneuver.
D: Mentum presentation would involve feeling the chin first, which is not the case in an RSA position.
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A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
- A. Placenta previa
- B. Prolapsed cord
- C. Incompetent cervix
- D. Abruptio placentae
Correct Answer: D
Rationale: The correct answer is D, abruptio placentae. This condition is characterized by sudden onset of continuous abdominal pain and vaginal bleeding, common at 36 weeks gestation with pregnancy-induced hypertension. It occurs when the placenta prematurely separates from the uterine wall. Placenta previa (A) presents painless bleeding, prolapsed cord (B) involves cord presenting before the fetus, and incompetent cervix (C) leads to painless dilation of the cervix. Thus, abruptio placentae is the most likely complication in this scenario.
A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?
- A. Maternal/newborn blood group incompatibility
- B. Absence of vitamin K
- C. Physiologic jaundice
- D. Maternal cocaine abuse
Correct Answer: A
Rationale: Step-by-step rationale for why the correct answer is A:
1. Maternal/newborn blood group incompatibility can result in hemolytic disease of the newborn.
2. Hemolytic disease causes an increase in bilirubin levels, leading to jaundice.
3. Jaundice in this case is due to the breakdown of red blood cells and elevated unconjugated bilirubin levels.
4. Physiologic jaundice is a normal process in newborns and usually appears after the first 24 hours of life.
5. Absence of vitamin K would not directly cause jaundice.
6. Maternal cocaine abuse is not typically associated with neonatal jaundice.
In summary, the correct answer is A because maternal/newborn blood group incompatibility can lead to hemolytic disease and subsequent jaundice, while the other choices are not directly related to neonatal jaundice.
When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?
- A. Perform a sharp hand clap near the infant.
- B. Hold the newborn vertically allowing one foot to touch the table surface.
- C. Place a finger at the base of the newborn's toes.
- D. Turn the newborn's head quickly to one side.
Correct Answer: A
Rationale: The correct answer is A: Perform a sharp hand clap near the infant. This action elicits the Moro reflex by stimulating the startle response. The Moro reflex involves the baby's arms spreading out and then coming back in when they feel like they are falling. This reflex helps in assessing the baby's neurological development. Choices B, C, and D do not specifically target the Moro reflex and may elicit other reflexes or responses. Holding the newborn vertically (B) may trigger the stepping reflex, placing a finger at the base of the toes (C) may provoke the Babinski reflex, and turning the newborn's head (D) may elicit the tonic neck reflex.
A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is a sign that precedes labor as the body may experience a burst of energy known as the "nesting instinct." This surge can occur as the body prepares for the upcoming physical demands of labor.
A: Decreased vaginal discharge is not a sign of impending labor; in fact, there may be an increase in vaginal discharge as the body prepares for childbirth.
C: Urinary retention is not a sign of impending labor and can be a symptom of other issues such as a urinary tract infection.
D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor approaching; weight fluctuations during pregnancy are common and can vary based on various factors.
A healthcare provider is assessing a newborn who has a coarctation of the aorta. Which of the following should the provider recognize as a clinical manifestation of coarctation of the aorta?
- A. Increased blood pressure in the arms with decreased blood pressure in the legs
- B. Decreased blood pressure in the arms with increased blood pressure in the legs
- C. Increased blood pressure in both the arms and the legs
- D. Decreased blood pressure in both the arms and the legs
Correct Answer: A
Rationale: The correct answer is A: Increased blood pressure in the arms with decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to increased blood pressure in the arms due to the pressure build-up before the narrowing and decreased blood pressure in the legs due to reduced blood flow beyond the narrowing. This pressure difference is a classic clinical manifestation of coarctation of the aorta.
Choices B, C, and D are incorrect because they do not align with the pathophysiology of coarctation of the aorta. B is incorrect as decreased blood pressure in the arms is not typical. C is incorrect as increased blood pressure in both the arms and legs does not reflect the characteristic pressure difference caused by the aortic narrowing. D is incorrect as decreased blood pressure in both the arms and legs is not consistent with the presentation of coarctation of the aorta.