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The nurse is caring for a client with gestational diabetes. What fetal complication should the nurse monitor for after birth?
- A. Hyperglycemia.
- B. Macrosomia.
- C. Hypoglycemia.
- D. Hyperbilirubinemia.
Correct Answer: C
Rationale: Newborns of mothers with gestational diabetes are at risk for hypoglycemia due to high insulin levels after birth.
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The nurse is preparing a client for a postpartum tubal ligation. What is the priority preoperative nursing action?
- A. Insert an indwelling catheter.
- B. Verify signed informed consent.
- C. Administer prescribed antibiotics.
- D. Check for maternal vital signs.
Correct Answer: B
Rationale: Verifying informed consent is essential before proceeding with any surgical procedure.
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take?
- A. Discontinue the medication infusion.
- B. Prepare for an emergency cesarean birth.
- C. Assess maternal blood glucose.
- D. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: The most appropriate action for the nurse to take in this situation is to discontinue the medication infusion. The client is showing signs of magnesium sulfate toxicity, which can include respiratory depression (low respiratory rate) and absent deep-tendon reflexes. These are early signs of magnesium toxicity, and prompt action is needed to prevent further complications. Discontinuing the medication infusion will help reduce the risk of magnesium toxicity worsening. The other options are not appropriate in this situation as they do not address the immediate concern of magnesium toxicity.
The nurse is assessing a client at 10 weeks' gestation. Which finding is expected?
- A. Quickening.
- B. Fetal heart tones by Doppler.
- C. Fundus at the level of the umbilicus.
- D. Presence of Braxton Hicks contractions.
Correct Answer: B
Rationale: Fetal heart tones can typically be detected by Doppler around 10 weeks' gestation.
What are the modes of heat loss in babies? SATA
- A. Radiation
- B. Conduction
- C. Convection
- D. Perspiration (baby's don't perspir
Correct Answer: A
Rationale: A. Radiation: Heat loss through radiation occurs when the baby is near a cold surface or in a drafty room, causing heat to transfer from the baby's body to the surrounding environment.
The nurse is teaching a client with a midline episiotomy about perineal care after vaginal birth. Which statement from the client indicates she
- B. I will use the perineal bottle without touching perineum each time going to the bathroom
- C. I will gently pat perineal dry rather than wipe
- D. I will only use the perineal bottle after bowel movements
Correct Answer: C
Rationale: This statement indicates a correct understanding of perineal care after a midline episiotomy. After vaginal birth, it is important to avoid wiping the perineal area to prevent irritation and infection. Instead, gently patting the area dry is recommended to promote healing and prevent discomfort. This approach helps to minimize trauma to the sensitive tissues of the perineum and reduces the risk of introducing bacteria from wiping.