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A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome (NAS) occurs in newborns exposed to addictive substances in utero. The newborn may exhibit symptoms such as excessive crying due to neurologic irritability. Diminished deep tendon reflexes (A) are not typically associated with NAS. Decreased muscle tone (C) is not a common finding in NAS; infants may actually have increased muscle tone. An absent Moro reflex (D) is not a typical finding in NAS, as hyperreflexia is more common.
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A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This helps to improve blood flow and circulation, which can help increase blood pressure in a hypotensive client. Placing the client on their side also helps prevent potential complications such as supine hypotension syndrome.
Choice B is incorrect because administering oxygen may not directly address the underlying cause of hypotension in this situation.
Choice C is incorrect as massaging the fundus is typically done to assess postpartum bleeding in women who have recently given birth, not for hypotension following epidural anesthesia.
Choice D is incorrect because while emptying the bladder can help in some cases of hypotension, it may not be the most immediate or appropriate action in this scenario.
Which of the following hormones stimulates uterine contractions during labor?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: D
Rationale: Oxytocin is the hormone responsible for stimulating uterine contractions during labor.
Which of the following is a professional standard for nursing practice in maternal and newborn healthcare?
- A. Collaboration with interdisciplinary team members
- B. Advocacy for patients and families
- C. Incorporation of evidence-based practice
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, all of the above. Collaboration with interdisciplinary team members is crucial in providing holistic care in maternal and newborn healthcare. Advocacy for patients and families ensures their rights and preferences are respected. Incorporation of evidence-based practice ensures that nursing care is based on the best available research and clinical expertise. Therefore, selecting all of the above options is essential to uphold professional standards in nursing practice in maternal and newborn healthcare.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The priority intervention is to begin FHR (fetal heart rate) monitoring to ensure the fetus is not in distress after the rupture of membranes. This is critical for fetal well-being.
What is the recommended method of pain relief during labor for a woman who wants to avoid medication?
- A. Breathing techniques
- B. Massage
- C. Water immersion
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Breathing techniques help manage pain by promoting relaxation and reducing stress. Massage can provide comfort and help relieve muscle tension. Water immersion, such as a warm bath or shower, can ease contractions and promote relaxation. Choosing all options provides a comprehensive approach to pain relief during labor without medication. Options A, B, and C individually offer effective non-pharmacological methods, but using them in combination (D) offers a more holistic and effective pain management strategy.