Nokea
The health care provider has determined that a preterm labor client at 34 weeks' gestation has no fetal fibronectin present. The nurse should assess the client for which of the following outcomes in the next week?
- A. The client will develop preeclampsia.
- B. The fetus will develop mature lungs.
- C. The client will not likely develop preterm labor.
- D. The fetus will not develop gestational diabetes.
Correct Answer: C
Rationale: Absence of fetal fibronectin indicates reduced likelihood of preterm labor.
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The nurse is working on a busy labor and delivery unit with other nurses and a licensed practical nurse. Which of the following labor clients would the nurse assign to the licensed practical nurse?
- A. A G 4, P 3 client with a history of gestational diabetes.
- B. A G 3, P 1, Ab 1 client at 35 weeks' gestation.
- C. A G 1, P 0 client with leaking green amniotic fluid.
- D. A G 2, P 1 client with a history of hyperemesis gravidarum.
Correct Answer: D
Rationale: A G 2, P 1 client with a history of hyperemesis gravidarum is low-risk, suitable for an LPN's scope (e.g., vital signs, basic care). Clients with gestational diabetes, preterm labor (35 weeks), or meconium-stained fluid (G 1, P 0) require RN assessment due to higher risk.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
A primigravid client at 34 weeks' gestation is experiencing contractions every 3 to 4 minutes lasting for 35 seconds. Her cervix is 2 cm dilated and 50% effaced. While the nurse is assessing the client's vital signs, the client says, "I think my bag of water just broke." Which of the following would the nurse do first?
- A. Check the status of the fetal heart rate.
- B. Turn the client to her right side.
- C. Test the leaking fluid with nitrazine paper.
- D. Perform a sterile vaginal examination.
Correct Answer: A
Rationale: Checking the fetal heart rate is the first action to ensure fetal well-being.
While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
- A. Red reflex in the eyes.
- B. Expiratory grunt.
- C. Respiratory rate of 45 breaths/minute.
- D. Prominent xiphoid process.
Correct Answer: B
Rationale: An expiratory grunt is a sign of respiratory distress and warrants immediate notification of the pediatrician.
During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?
- A. Wipe off any lanolin creams from the nipple before each feeding.
- B. Position the baby with the entire areola in the baby's mouth.
- C. Feed the baby less often for the next several days.
- D. Use a mild soap while in the shower to prevent an infection.
Correct Answer: B
Rationale: Proper positioning with the areola in the baby's mouth prevents and heals sore nipples.