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During vaginal delivery, newborn's head emerges
During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that
- A. The cord is still pulsating.
- B. The cord is intact.
- C. No part of the cord is encircling the baby's neck.
- D. The cord is still attached to the placenta.
Correct Answer: C
Rationale: Checking for a nuchal cord (cord around the neck) is critical to prevent compression, which could reduce blood flow and oxygen to the baby.
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Postpartum woman, 4-day-old infant, breastfeeding
A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:
- A. has at least six to eight wet diapers per day.
- B. has at least one breast milk stool every 24 hours.
- C. sleeps for 6 hours at a time between feedings.
- D. gains 1 to 2 ounces per week.
Correct Answer: A
Rationale: Six to eight wet diapers per day indicate adequate hydration and milk intake, a reliable sign of effective breastfeeding.
Woman received epidural or intrathecal opioids
The main nursing observations of the woman who receives epidural or intrathecal opioids are for all except
- A. delayed respiratory depression.
- B. inability to move lower extremities.
- C. pruritus.
- D. nausea and vomiting.
Correct Answer: A
Rationale: Delayed respiratory depression is not a primary concern with epidural or intrathecal opioids, which have limited systemic effects compared to systemic opioids.
Laboring woman
The most appropriate time for the nurse to encourage a laboring woman to push is during
- A. the interval between contractions.
- B. whenever she feels the need.
- C. second-stage of labor.
- D. first-stage of labor.
Correct Answer: C
Rationale: The second stage of labor, when the cervix is fully dilated, is the appropriate time to push, as contractions are strong and effective for delivery.
Newborn reflex observation
What reflex is elicited: Fanning of toes when stroking lateral edge of baby's foot?
- A. Babinski's Reflex.
- B. Stepping Reflex.
- C. Moro reflex.
- D. Plantar Grasp reflex.
Correct Answer: A
Rationale: Babinski's Reflex is elicited by fanning of the toes when the lateral edge of the foot is stroked, normal in infants up to 2 years.
Newborn boy, 1 minute after birth, heart rate 138 bpm, vigorous crying, spontaneous movement, pink skin with bluish hands and feet
Erin gives birth to a boy. The nurse notes the following on the baby at 1 minute: heart rate is 138 bpm, loud vigorous crying, spontaneous movement and flexion of the extremities, and pink skin color except for a bluish color of the hands and feet. What Apgar score will be assigned to the baby?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: B
Rationale: The baby scores 2 for heart rate (>100 bpm), 2 for respiratory effort (vigorous crying), 2 for muscle tone (spontaneous movement), 2 for reflex irritability (crying), and 1 for color (acrocyanosis), totaling an Apgar score of 8.