Nokea
The nurse is caring for a pregnant client who was sent to the hospital for a biophysical profile. She is 37 weeks gestation with her second child, has gestational diabetes, and complains of decreased fetal movement for the last 24 hours. Which action should the nurse take first?
- A. Perform vital signs
- B. Call physician
- C. Perform glucose
- D. Place on fetal monitor
Correct Answer: D
Rationale: The correct answer is D: Place on fetal monitor. This action is crucial to assess the fetal well-being and monitor the baby's heart rate and movements. It helps in determining if the baby is in distress and requires immediate intervention. Performing vital signs (A) is important but not the priority in this situation. Calling the physician (B) can be done after the initial assessment on the fetal monitor. Performing glucose (C) is not the priority when the main concern is the well-being of the baby.
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It is noted that a baby admitted to the nursery has translucent skin with visible veins. Because of this finding, the nurse should monitor this baby carefully for which of the following?
- A. Polycythemia.
- B. Hypothermia.
- C. Hyperglycemia.
- D. Polyuria.
Correct Answer: B
Rationale: Translucent skin with visible veins is common in preterm infants, who are at higher risk for hypothermia due to poor thermoregulation.
A nurse has provided a young woman with preconception counseling. Which of the statements by the woman indicates that the teaching was successful? Select all that apply.
- A. “As soon as I think I may be pregnant, I should stop drinking alcohol.”
- B. “It is important for me to see my medical doctor for a complete physical.”
- C. “I should make sure that my daily multivitamin contains folic acid.”
- D. “When I go to my dentist for a checkup I should state that I may be pregnant.”
Correct Answer: A
Rationale: All the statements indicate successful preconception counseling, covering topics such as alcohol cessation, medical checkups, folic acid intake, dental care, and dietary precautions.
A patient with an IUD in place has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action?
- A. A therapeutic abortion will need to be scheduled since fetal damage is inevitable.
- B. Hormonal analyses will be done to determine the underlying cause of the false-positive test result.
- C. The IUD will need to be removed to avoid complications such as miscarriage or infection.
- D. The IUD will need to remain in place to avoid injuring the fetus.
Correct Answer: C
Rationale: Rationale:
C is correct because when a patient with an IUD in place has a positive pregnancy test, the IUD should be removed to avoid complications such as ectopic pregnancy, miscarriage, or infection. Leaving the IUD in place can increase the risk of adverse outcomes for both the mother and the fetus. Removing the IUD allows for safer management of the pregnancy and reduces potential harm.
Summary:
A: Incorrect. Fetal damage is not inevitable, and a therapeutic abortion is not the immediate action required in this situation.
B: Incorrect. Hormonal analyses are not the priority when a positive pregnancy test with an IUD in place is detected.
D: Incorrect. Leaving the IUD in place can lead to complications and is not the recommended course of action.
A neonate in the nursery, whose mother had no prenatal care, has been diagnosed with macrosomia. For which of the following signs/symptoms should the nurse carefully monitor this baby?
- A. Jaundice.
- B. Jitters.
- C. Blepharitis.
- D. Strabismus.
Correct Answer: B
Rationale: Macrosomic babies are at risk for hypoglycemia, which can present as jitteriness.
A mother questions the nurse about when the newborn screening tests for inborn diseases will be performed. Which of the following is an appropriate response by the nurse?
- A. The doctor took blood from the baby's umbilical cord at birth.
- B. A sample of the baby's first urine and first stool were sent for testing.
- C. A vial of blood was drawn and sent when the baby was admitted to the nursery.
- D. Blood from the baby's heel was sent after the baby had been fed a few times.
Correct Answer: D
Rationale: Newborn screening tests are typically done by collecting blood from the baby's heel after the baby has been fed a few times to ensure accurate results.