Nokea
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.
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The menstrual phase of the menstrual cycle is characterized by what?
- A. shedding of the endometrial lining
- B. ovulation
- C. fertilization
- D. implantation
Correct Answer: A
Rationale:
On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.
Which of the following interpretations of this finding should the nurse make?
- A. The presenting part is 1 cm above the ischial spines.
- B. The presenting part is 1 cm below the ischial spines.
- C. The cervix is 1 cm dilated.
- D. The cervix is effaced 1 cm.
Correct Answer: A
Rationale: The finding of "station -1" indicates that the presenting part of the baby is 1 cm above the ischial spines in the mother's pelvis. Station is a measurement used in obstetrics to describe the position of the presenting part of the fetus in relation to the ischial spines of the mother's pelvis during labor. Stations are measured in centimeters and range from -5 (highest) to +5 (lowest). In this case, a station of -1 means the baby's presenting part is 1 cm above the ischial spines. This information helps healthcare providers assess the progress of labor and determine the positioning of the baby during delivery.
The physician has determined the need for forceps. The nurse should explain to the patient that the need for forceps is indicated because
- A. Premature placental separation (also used for prolapsed cord and nonreasoning fetal HR)
- B. Her support person is exhausted
- C. To shorten the first stage of labor
- D. To prevent fetal distress
Correct Answer: A
Rationale: Forceps delivery is indicated in situations where there is fetal distress due to premature placental separation or nonreassuring fetal heart rate. Forceps are used to facilitate a quicker delivery and reduce the risk to the baby during such emergency situations. Forces are also used in cases of fetal distress due to a prolapsed cord where a quick delivery is necessary to relieve pressure on the umbilical cord.
The nurse is caring for a pregnant client with a diagnosis of gestational diabetes. What finding indicates the need for immediate intervention?
- A. Blood sugar of 130 mg/dL after a meal.
- B. Fasting blood sugar of 95 mg/dL.
- C. Presence of ketones in the urine.
- D. Client reports increased thirst.
Correct Answer: C
Rationale: Ketones in the urine indicate poor glucose control and possible ketoacidosis, requiring urgent medical attention.