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The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?
- A. Elicit positive scarf sign on the affected side
- B. Observe for an asymmetrical Moro (startle) reflex
- C. Watch for swelling of fingers on the affected side
- D. Note paralysis of affected extremity and muscles
Correct Answer: B
Rationale: The most common neonatal birth trauma due to vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fracture clavicle should be suspected is an infant has limited use of the affected arm malposition of the arm, an asymmetric Moro reflex (B), crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved.
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A client at 39-weeks gestation is admitted to the labor and delivery unit in active labor. The client's cervix is dilated 7 cm, 100% effaced, and the fetus is at +1 station. The client begins to push forcefully with contractions. What action should the nurse take?
- A. Encourage the client to pant-blow during contractions.
- B. Assist the client to push with contractions.
- C. Prepare for an immediate delivery.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Pant-blow breathing helps prevent premature pushing before full dilation, reducing the risk of cervical edema.
A pregnant patient arrives for her first prenatal visit at the clinic. She informs the nurse that she has been taking an additional 400 mcg of folic acid prior to becoming pregnant. Based on the patient's history, she has reached 8 weeks' gestation. Which recommendation would the nurse provide regarding folic acid supplementation?
- A. Have the patient continue to take 400 mcg folic acid throughout her pregnancy.
- B. Tell the patient that she no longer has to take additional folic acid because it will be included in her prenatal vitamins.
- C. Have the patient increase her folic acid intake to 1000 mcg throughout the rest of her pregnancy.
- D. Schedule the patient to go for an AFP (alpha-fetoprotein) test.
Correct Answer: B
Rationale: Step 1: The patient has been taking an additional 400 mcg of folic acid prior to pregnancy.
Step 2: Folic acid is crucial in the early stages of pregnancy for neural tube development.
Step 3: By 8 weeks' gestation, the neural tube has already formed.
Step 4: Prenatal vitamins typically contain the recommended amount of folic acid.
Step 5: Therefore, the nurse would recommend the patient to stop taking additional folic acid as it's included in prenatal vitamins.
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching on the gravid client?
- A. The client's readiness to learn
- B. The client's educational background
- C. The order in which the information is presented
- D. The extent to which the pregnancy was planned
Correct Answer: A
Rationale: When teaching any client, readiness to learn (A) is the most important criterion. For example, the client with severe morning sickness in the first trimester may not be 'ready to learn' about ways to relieve morning sickness.
A hospital has achieved Magnet status. Which indicators would be consistent with this type of certification?
- A. There is stratification of communication in a directed manner between nursing staff and administration.
- B. There is increased job satisfaction of nurses, with a lower staff turnover rate.
- C. Physicians are certified in their respective specialty areas.
- D. All nurses have baccalaureate degrees and certification in their clinical specialty area.
Correct Answer: B
Rationale: Magnet status hospitals demonstrate higher nurse job satisfaction and lower turnover rates, along with improved quality of care.
A diabetic client delivers a full-term large for gestation-age (LGA) infant who is jittery. What action should the nurse take first?
- A. Administer oxygen
- B. Feed the infant glucose water (10%)
- C. Obtain a blood glucose level
- D. Decrease environment stimuli
Correct Answer: C
Rationale: Jitteriness in LGA infants suggests hypoglycemia, so obtaining a blood glucose level (C) is the priority.