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The nurse is conducting a prenatal class about amniotic fluid. Which characteristics should be included in the teaching?
- A. Allows for fetal movement.
- B. Surrounds, cushions, and protects the fetus.
- C. Maintains the body temperature of the fetus.
- D. Can be used to measure fetal kidney function.
Correct Answer: B
Rationale: Amniotic fluid serves multiple functions, including cushioning the fetus, temperature regulation, and monitoring fetal kidney health.
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The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: C
Rationale: Neonatal weight loss in the first 3 days of life is most often the result of inadequate breast or formula feeding. During the initial days of life, it is normal for newborn babies to experience some weight loss. This weight loss is generally due to factors such as insufficient intake of breast milk or formula. It takes a few days for a mother's mature breast milk to come in, and during this time, a newborn may not receive enough colostrum, which can lead to initial weight loss. Similarly, if a baby is not getting enough formula or is having feeding difficulties, this can also result in weight loss. Allergy to formula, a hypoglycemic response, or excretion of fluid via lungs, urinary bladder, and bowels are less likely explanations for neonatal weight loss in the first 3 days of life compared to inadequate feeding.
The nurse is preparing a client for a postpartum tubal ligation. What is the priority preoperative nursing action?
- A. Insert an indwelling catheter.
- B. Verify signed informed consent.
- C. Administer prescribed antibiotics.
- D. Check for maternal vital signs.
Correct Answer: B
Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.
A patient asks the nurse about using the basal body temperature method as contraception. What statement made by the patient indicates that the patient needs further teaching?
- A. “I need to take my temperature before I even sit up in bed.â€
- B. “A rise of 0.4° F above my baseline temperatures for 3 days indicates it is safe to have condomless sex.â€
- C. “I need to use a special thermometer to take my basal body temperature.â€
- D. “I know I am about to ovulate when my temperature rises at least 0.4° F.â€
Correct Answer: B
Rationale: Option B is the statement made by the patient that indicates the need for further teaching. In the basal body temperature method of contraception, a sustained temperature rise typically indicates ovulation has already occurred, making it unsafe to have condomless sex. It is the drop in temperature just before ovulation that is used to predict a fertile window. Therefore, a rise in temperature would not indicate that it is safe to have condomless sex. The patient should be educated that the temperature shift indicates the end of the fertile window and that it is safest to avoid unprotected sex during the fertile window.