Nokea
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.
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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 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.
During a client's active labor, a healthcare provider notes that the presenting part is at 0 station. What is the correct interpretation of this clinical finding?
- A. The fetal head is in the left occiput posterior position.
- B. The largest fetal diameter has passed through the pelvic outlet.
- C. The posterior fontanel is palpable.
- D. The lowermost portion of the fetus is at the level of the ischial spines.
Correct Answer: D
Rationale: The correct interpretation of 0 station is that the lowermost portion of the fetus is at the level of the ischial spines. This indicates the descent of the fetus into the birth canal. At 0 station, the presenting part has not yet passed through the pelvic outlet, ruling out choice B. Choices A and C are incorrect as they refer to different aspects of fetal positioning and fontanel palpation, not specifically related to station. Therefore, the correct answer is D as it directly relates to the position of the fetus in the birth canal.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
- A. Fetal attitude is in general flexion.
- B. Fetal lie is longitudinal.
- C. Maternal pelvis is gynecoid.
- D. Fetal position is persistent occiput posterior.
Correct Answer: D
Rationale: The correct answer is D: Fetal position is persistent occiput posterior. This position, where the baby's head is facing the mother's abdomen instead of her back, can lead to severe backache and difficulty during labor due to increased pressure on the mother's spine. This malposition can impede the progress of labor and cause prolonged labor.
Explanation of incorrect choices:
A: Fetal attitude in general flexion is a normal position and not typically associated with severe backache.
B: Fetal lie being longitudinal refers to the baby's position in relation to the mother's spine and is not directly related to backache.
C: Maternal pelvis being gynecoid is a favorable shape for childbirth and is unlikely to cause severe backache during labor.
During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?
- A. Acrocyanosis of hands and feet
- B. Anterior fontanel soft and level
- C. Plantar creases cover 2/3 of sole
- D. Vernix caseosa in inguinal creases
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
Plantar creases covering 2/3 of the sole is a standard newborn assessment finding indicating normal development. This is a key milestone in assessing the newborn's muscle tone and neurological status. Absence or presence of plantar creases can provide insights into potential developmental issues. Therefore, recording this finding is crucial for monitoring the newborn's growth and development.
Summary of Other Choices:
A: Acrocyanosis of hands and feet - Common benign finding in newborns due to immature circulation, not a specific part of newborn assessment.
B: Anterior fontanel soft and level - Important assessment, but not specific to gestational age assessment.
D: Vernix caseosa in inguinal creases - Normal finding, but not a specific part of gestational age assessment.