Nokea
A new mother states that her infant must be cold because the baby's head and feet are blue? The nurse should explain that this is a common and temporary condition called:
- A. Acrocyanosis
- B. Vernix caseosa
- C. Erythema neonatorum
- D. Harlequin color
Correct Answer: A
Rationale: Acrocyanosis is a common and benign condition in newborn infants characterized by temporary blueness or cyanosis of the hands, feet, and sometimes the face. This blueness is caused by the temporary constriction of blood vessels in those areas, resulting in reduced blood flow and less oxygen reaching the skin. Acrocyanosis typically resolves on its own and does not indicate any serious health concerns in newborns. It is important for healthcare providers to reassure parents that acrocyanosis is a normal phenomenon in newborns and does not require treatment.
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A nurse is caring for a client who is in preterm labor at 32 weeks of gestation. The client asks the nurse, "Will my baby be okay?" Which of the following responses should the nurse offer?
- A. "You must be feeling scared and powerless."
- B. "Everyone worries about her baby when she's in labor."
- C. "Your pregnancy is advanced so your baby should be fine."
- D. "We have a neonatal unit here that's equipped to handle emergencies."
Correct Answer: D
Rationale: The most appropriate response for the nurse to offer in this situation is to inform the client that there is a neonatal unit equipped to handle emergencies. This response provides the client with reassurance that if there are any complications with the baby being born prematurely, there is a specialized unit available to provide the necessary care. It addresses the client's concern about the well-being of her baby while also offering a practical solution in case of any emergencies.
A nurse is doing genetic counseling with a couple. give to a client undergoing a mastectomy? The mother has Down syndrome and the father
- A. Tylenol should be avoided after surgery. has no chromosomal abnormalities. What is the
- B. The affected arm should remain in a sling for chance of their offspring being affected by this 4 weeks. disorder?
- C. The client should expect the affected arm to be
- D. 25%
Correct Answer: D
Rationale: When a woman with Down syndrome (trisomy 21) has a child with a man who does not have any chromosomal abnormalities, the chance of their offspring having Down syndrome is 25%. This is because the mother can only pass on one copy of the extra chromosome 21 to her child, resulting in a 50% chance of passing it on. However, since the father does not have an extra chromosome 21 to contribute, the overall chance of the child having Down syndrome is reduced to 25%.
Which client would be at greatest risk for developing
- A. Thick breast cancer?
- B. Wet/slippery with egg white consistency
- C. Client who had her first baby at the age of 24
- D. Client who did not breastfeed
Correct Answer: D
Rationale: Not breastfeeding has been identified as a risk factor for developing breast cancer. Breastfeeding has been shown to have a protective effect against breast cancer due to its impact on hormonal levels and breast tissue changes that occur during lactation. Therefore, compared to other options, the client who did not breastfeed would be at greater risk for developing breast cancer.
A client at 12 weeks' gestation asks why folic acid is important during pregnancy. What is the nurse's best response?
- A. It helps prevent gestational diabetes.
- B. It promotes fetal brain development.
- C. It reduces the risk of neural tube defects.
- D. It increases maternal energy levels.
Correct Answer: C
Rationale: Folic acid is essential during early pregnancy to reduce the risk of neural tube defects like spina bifida.
A client at 28 weeks' gestation reports uterine contractions every 10 minutes. What is the priority nursing action?
- A. Encourage rest and hydration.
- B. Assess for signs of preterm labor.
- C. Administer tocolytic medication.
- D. Perform a vaginal examination.
Correct Answer: B
Rationale: Assessing for preterm labor signs, including cervical changes, is critical to determine the appropriate intervention.