The nurse assigned to the care of newborn infants understands the importance of keeping these infants swaddled in a warm blanket to prevent heat loss. Why is this important in the care of the newborn?
- A. Chilling leads to increased heat production and greater oxygen needs.
- B. The newborn's metabolic rate is decreased.
- C. Evaporation will affect the newborn's ability to feed.
- D. The newborn will sleep more comfortably.
Correct Answer: A
Rationale: Swaddling newborn infants in a warm blanket is important to prevent heat loss (hypothermia) because when babies become chilled, they must produce more heat to maintain a normal body temperature. This increased heat production leads to higher oxygen needs, which can be detrimental to newborns who may already have limited reserves. Therefore, keeping newborn infants swaddled in a warm blanket helps to maintain their body temperature within a normal range and prevents unnecessary stress on their bodies.
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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.
Which environment can assist a pregnant teen to achieve the task of establishing a stable identity?
- A. Home schooling
- B. Alternative education program
- C. School-based mothers' program
- D. Continuing mainstream high school classes
Correct Answer: C
Rationale: A school-based mothers' program can assist a pregnant teen in establishing a stable identity by providing specialized support and resources tailored to their unique needs. These programs typically offer academic assistance, childcare services, counseling, and parenting classes. By being in a supportive and understanding environment with other young mothers, the pregnant teen can feel accepted and supported, which can help boost her self-esteem and confidence. Additionally, these programs often focus on empowering young mothers to continue their education and set goals for their future, contributing to the development of a stable identity.
The nurse provides counseling on coitus interruptus. What important counseling should be included?
- A. The partners must communicate well to use this method.
- B. This method is 100 percent effective because semen does not enter the vagina.
- C. BBT must be used with this method.
- D. All persons are able to control ejaculate in time to withdraw.
Correct Answer: A
Rationale: The important counseling that should be included when discussing coitus interruptus (withdrawal method) is that the partners must communicate well to use this method effectively. Coitus interruptus involves the male partner withdrawing his penis from the vagina before ejaculation to prevent sperm from entering the woman's reproductive tract. Effective communication between partners is crucial to ensure that the method is used correctly and consistently. This method does not protect against sexually transmitted infections (STIs), so it's also important to discuss alternative methods of contraception for STI prevention. The statement that this method is 100 percent effective is incorrect, as pre-ejaculate can contain sperm and there is a risk of pregnancy if withdrawal is not done correctly.
A client in labor with a breech presentation is scheduled for a cesarean delivery. What is the nurse's priority action?
- A. Obtain baseline maternal vital signs.
- B. Assist with positioning for spinal anesthesia.
- C. Verify fetal heart tones before the procedure.
- D. Ensure signed informed consent is on file.
Correct Answer: D
Rationale: Ensuring signed informed consent is a priority before any surgical procedure, including cesarean delivery.
A nurse is caring for a client who is in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following actions should the nurse
- A. Assist the client into a comfortable position.
- B. Observe the perineum for signs of crowning.
- C. Have the client pant during the next contractions.
- D. Help the client to the bathroom to void.
Correct Answer: B
Rationale: The sudden urge to push along with the advanced cervical dilation, effacement, and station indicates that the client is likely in the second stage of labor, which is the stage of active pushing. When a woman feels the urge to push, it is essential to assess for the crowning of the fetal head at the perineum as this indicates that the baby is descending and will soon be born. This assessment helps the nurse determine the appropriate actions to take next in assisting the delivery process. Waiting for signs of crowning before guiding the client to push can prevent potential complications related to a rapid birth and help facilitate a more controlled delivery process.