Nokea
Shortly after birth, the nurse measures the circumference of a term neonate's head and chest. When the two measurements are compared, which of the following would the nurse expect to find about the head circumference?
- A. Equal to the chest circumference.
- B. Approximately $2 \mathrm{~cm}$ larger than the chest.
- C. About $3 \mathrm{~cm}$ smaller than the chest.
- D. Approximately $4 \mathrm{~cm}$ larger than the chest.
Correct Answer: B
Rationale: In a term neonate, the head circumference is typically about 2 cm larger than the chest circumference.
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A multigravid client at term is admitted to the hospital for a trial labor and possible vaginal birth. She has a history of previous cesarean delivery because of fetal distress. When the client is 4 cm dilated, she receives nalbuphine (Nubain) intravenously. While monitoring the fetal heart rate, the nurse observes minimal variability and a rate of 120 bpm. The nurse should explain the decreased variability is most likely caused by which of the following?
- A. Maternal fatigue.
- B. Fetal malposition.
- C. Small-for-gestational-age fetus.
- D. Effects of analgesic medication.
Correct Answer: D
Rationale: Nalbuphine, an opioid, can reduce fetal heart rate variability by depressing the central nervous system, a common side effect. Maternal fatigue, malposition, or small-for-gestational-age fetus are less likely causes.
The labor and delivery nurse is assigned to triage for the day. There are four clients already in rooms and the following reports have been received about each of these clients. To provide the safest care and best manage time, the nurse should plan to see which client first?
- A. A primipara in active labor at 5 cm asking to be admitted and wanting an epidural.
- B. A primipara who is 100% effaced, 8 cm dilated, and ready to push.
- C. A multipara who thinks her water broke 2 hours ago.
- D. A multipara with contractions every 5 minutes who is 3 cm dilated.
Correct Answer: B
Rationale: A primipara at 8 cm, 100% effaced, and ready to push is in the second stage of labor, requiring immediate attention to prepare for delivery. Other clients are in earlier stages or need assessment but are less urgent.
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. Which of the following should the nurse do first?
- A. Insert an airway to improve oxygenation.
- B. Note the time when the seizure begins and ends.
- C. Call for immediate assistance.
- D. Turn the client to her left side.
Correct Answer: D
Rationale: Turning the client to her left side helps maintain airway patency and prevents aspiration.
After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?
- A. I should clean her mouth with soapy water after feeding.'
- B. I should feed her in an upright position.'
- C. I need to remember to burp her often.'
- D. I may need to use a special nipple for feeding.'
Correct Answer: A
Rationale: Cleaning the mouth with soapy water is inappropriate and could irritate the cleft, indicating a need for further instruction.
A newly delivered client is asking to go to the bathroom 45 minutes after delivery. She had an epidural for labor & delivery, has an IV infusing, and every 15 minutes assessments are in progress. To provide the safest care for this client the nurse should:
- A. Ask her to remain in bed until the 15-minute assessments are complete.
- B. Assess client's ability to stand and bear weight before going to the bathroom.
- C. Encourage the client to sit at the side of the bed before ambulating to the bathroom.
- D. Ask the client to ambulate the first time with a staff member at her side.
Correct Answer: B
Rationale: Post-epidural, assessing the client's ability to stand and bear weight ensures safety due to potential residual numbness or weakness. Remaining in bed delays care, sitting first is insufficient, and ambulating with assistance assumes mobility not yet confirmed.