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The nurse is caring for a baby whose blood type is A+ (positive) and direct Coombs’ test is + (positive), and whose mother’s blood type is O+ (positive). Which of the following nursing diagnoses is appropriate for this baby?
- A. Risk for injury to the central nervous system.
- B. Risk for fluid volume deficit.
- C. Risk for interrupted family processes.
- D. Risk for impaired parent-infant attachment.
Correct Answer: A
Rationale: A positive Coombs’ test indicates hemolytic disease of the newborn, which can lead to bilirubin buildup and potential central nervous system damage.
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A client has just received synthetic prostaglandins for the induction of labor. The nurse plans to monitor the client for which of the following side effects?
- A. Nausea and uterine tetany.
- B. Hypertension and vaginal bleeding.
- C. Urinary retention and severe headache.
- D. Bradycardia and hypothermia.
Correct Answer: A
Rationale: Synthetic prostaglandins can cause nausea and uterine tetany, which are common side effects. The nurse should monitor for these and other potential complications.
The nurse is providing education to a patient at 16 weeks' gestation who is undecided about consenting to the quad screen. How can the nurse explain the purpose of the quad screen to the patient?
- A. It indicates the risk of the fetus for heart defects.
- B. It indicates the risk of the fetus for neural tube defects.
- C. It indicates the risk of the fetus for neural tube defects and chromosome abnormalities.
- D. It indicates the risk of the fetus for chromosome abnormalities.
Correct Answer: C
Rationale: The correct answer is C because the quad screen is a prenatal screening test that assesses the risk of the fetus for neural tube defects and chromosome abnormalities. At 16 weeks' gestation, this test helps identify potential issues early on, allowing for further diagnostic testing and appropriate interventions if needed. Choice A is incorrect because the quad screen does not specifically target heart defects. Choice B is incorrect as the quad screen does not solely focus on neural tube defects. Choice D is incorrect because the quad screen assesses both neural tube defects and chromosome abnormalities, not just chromosome abnormalities alone. Therefore, choice C is the most comprehensive and accurate explanation of the purpose of the quad screen for the patient at 16 weeks' gestation.
A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing?
- A. Primary care
- B. Preventive care
- C. Restorative care
- D. Continuing care
Correct Answer: B
Rationale: Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation.
A client asks the nurse, “Could you explain how the baby’s blood and my blood separate at delivery?” Which of the following responses is appropriate for the nurse to make?
- A. “When the placenta is born, the circulatory systems separate.”
- B. “When the doctor clamps the cord, the blood stops mixing.”
- C. “The separation happens after the baby takes the first breath. The baby’s oxygen no longer has to come from you.”
- D. “The blood actually never mixes. Your blood supply and the baby’s blood supply are completely separate.”
Correct Answer: D
Rationale: The maternal and fetal blood supplies are separate throughout pregnancy, with oxygen and nutrients exchanged through the placenta.
A breastfeeding client asks the nurse to make sure that her newborn is positioned and latched well at the breast. Which of the following assessments would indicate that the baby is poorly latched?
- A. The baby swallows after every suckle.
- B. The baby’s body is facing the mother’s body.
- C. The baby’s lower lip is curled under.
- D. The baby is lying at the level of the mother’s breasts.
Correct Answer: C
Rationale: A curled-under lower lip indicates poor latching, which can lead to ineffective feeding and nipple damage.