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The nurse is caring for a client with gestational diabetes. What complication should the nurse monitor for during labor?
- A. Placental abruption.
- B. Macrosomia.
- C. Preterm labor.
- D. Postpartum hemorrhage.
Correct Answer: B
Rationale: Macrosomia is a common complication of gestational diabetes, increasing the risk of delivery challenges.
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A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn's visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to addictive drugs in utero, commonly seen in infants born to mothers with substance use disorders. These babies often experience withdrawal symptoms such as tremors, irritability, and difficulty sleeping. Swaddling the newborn in a flexed position can help provide comfort and security to the infant, which may help alleviate some of the withdrawal symptoms they are experiencing. This intervention can also mimic the snug environment of the womb, promoting a sense of calmness for the newborn. It is important to create a soothing environment to aid in the management of NAS symptoms.
The nurse is preparing a client for cesarean delivery. What is the priority nursing action?
- A. Obtain baseline vital signs.
- B. Insert an indwelling urinary catheter.
- C. Verify signed informed consent.
- D. Administer prophylactic antibiotics.
Correct Answer: C
Rationale: Ensuring informed consent is signed is a priority before any surgical procedure.
Which intervention is most critical for a mother with a uterine atony postpartum?
- A. Perform uterine massage
- B. Administer oxytocin infusion
- C. Monitor blood pressure and pulse frequently
- D. Encourage breastfeeding to stimulate uterine contractions
Correct Answer: A
Rationale: Performing uterine massage helps contract the uterus and reduce bleeding in uterine atony.
A new mother states that her infant must be cold because the baby's head and feet are blue? The nurse should explain that this is a common and temporary condition called:
- A. Acrocyanosis
- B. Vernix caseosa
- C. Erythema neonatorum
- D. Harlequin color
Correct Answer: A
Rationale: Acrocyanosis is a common and benign condition in newborn infants characterized by temporary blueness or cyanosis of the hands, feet, and sometimes the face. This blueness is caused by the temporary constriction of blood vessels in those areas, resulting in reduced blood flow and less oxygen reaching the skin. Acrocyanosis typically resolves on its own and does not indicate any serious health concerns in newborns. It is important for healthcare providers to reassure parents that acrocyanosis is a normal phenomenon in newborns and does not require treatment.
The nurse is monitoring a pregnant client undergoing a nonstress test. What is a reassuring finding?
- A. Two accelerations in 20 minutes.
- B. Baseline fetal heart rate of 170 beats/minute.
- C. Decreased fetal movement.
- D. Variable decelerations.
Correct Answer: A
Rationale: Two accelerations within 20 minutes indicate a reactive and reassuring nonstress test result.