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An African American woman noticed bruises on a newborn girl's buttocks, and she asks the nurse who spanked the baby? The nurse responds
- A. Mongolian spots
- B. Ecchymosis
- C. Birth trauma
- D. Petechiae
Correct Answer: A
Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.
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A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.
What role do nurses play in addressing social determinants of health (SDOH)?
- A. Nurses primarily focus on providing medical treatments and interventions.
- B. Nurses have no role in addressing social determinants of health.
- C. Nurses are crucial in identifying and addressing the environmental factors that impact health outcomes.
- D. Nurses solely focus on the physical well-being of individuals and do not address social factors.
Correct Answer: C
Rationale:
A client at 36 weeks' gestation reports frequent urination and lower back pain. What should the nurse assess for?
- A. Preterm labor.
- B. Urinary tract infection.
- C. Normal third-trimester changes.
- D. Preeclampsia.
Correct Answer: A
Rationale: Frequent urination and back pain at 36 weeks may indicate preterm labor and require further assessment.
The nurse is monitoring a client at 39 weeks' gestation receiving oxytocin for labor induction. What finding requires the nurse to stop the infusion?
- A. Contractions every 2–3 minutes.
- B. Contractions lasting 120 seconds.
- C. Baseline fetal heart rate of 140 beats/minute.
- D. Client reports mild back pain.
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds indicate uterine hyperstimulation and can compromise fetal oxygenation.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Prepare the client for an immediate birth.
- C. Place the client in knee-chest position.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord. Rationale: This is the first nursing action because it is essential to prevent any pressure on the umbilical cord to promote oxygenation of the fetus.
Correct Answer: D
Rationale: The correct action for the nurse to perform first when observing the umbilical cord protruding from the vagina during the first stage of labor is to insert a gloved hand into the vagina to relieve pressure on the cord. This is crucial to prevent compression of the cord, which could compromise oxygenation to the fetus. By gently lifting the presenting part off the cord, the nurse can help maintain blood flow and prevent fetal distress. Once the pressure on the cord is relieved, additional interventions such as preparing the client for immediate birth, covering the cord with a sterile, moist saline dressing, or positioning the client in knee-chest position may be necessary depending on the clinical situation. But the priority is to relieve pressure on the umbilical cord promptly to ensure the well-being of the fetus.