Nokea
The nurse is doing a one-minute Apgar score on a newborn and tells the parents that it is 7 points. When the parents ask what this means, how should the nurse best respond?
- A. “This score is good, but the baby needs to have a score of 10 in five minutes.”
- B. “The Apgar score can predict intelligence and neurological development.”
- C. “Your baby is fine and should have no difficulty adapting outside the womb.”
- D. “Your baby has good vital signs and is classified as full-term gestational age.”
Correct Answer: C
Rationale: This response is best because a score of 7 to 10 is within a normal range and 并表示新生儿没有任何不适的迹象。A score of 7 to 10 is considered acceptable for a one-minute Apgar. However, when the scoring is repeated at 5 minutes of age, a score of 7 to 10, not just 10, is within normal range. The Apgar score is used to systematically assess an infant at one and five minutes after birth to determine if immediate care is necessary. It is not used to predict intelligence or neurological development. Although the Apgar score does mean that the newborn’s VS are WNL, the Apgar score is not designed to classify gestational age.
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The nurse advises the client that this test is typically performed at what time during the pregnancy?
- A. Just after the pregnancy is confirmed
- B. Early in the second trimester
- C. In the transition phase of labor
- D. Just after the first fetal movements
Correct Answer: B
Rationale: Amniocentesis is typically performed early in the second trimester (15-20 weeks) to assess for genetic abnormalities.
The pregnant client and her significant other are attending childbirth classes. The client asks for guidance on preparing her school-aged child for the new baby’s birth. Which strategies might the nurse suggest that the client use with her child? Select all that apply.
- A. Read books about bringing home a new baby.
- B. Think of unique names for the new baby.
- C. Help pack a bag for bringing the new baby home.
- D. Explain how pregnancy occurred, if asked.
- E. Help the child buy presents for the new baby.
Correct Answer: A,B,C,E
Rationale: Engaging the child in activities such as reading books about bringing the new baby home helps the child to feel a part of the experience. Engaging the child in activities such as naming the new baby helps the child to feel a part of the experience. Engaging the child in activities such as packing a bag for the new baby’s coming home helps the child to feel a part of the experience. Engaging the child in activities such as buying presents for the new baby helps the child to feel a part of the experience. Children younger than adolescents do not fully understand conception and pregnancy due to preoperational and concrete operational thinking. They are not usually asking for an explanation of sex during this time.
The nurse reviews information and assesses the laboring client at 42 weeks’ gestation before an HCP induces labor. Which findings should be reported to the HCP because they are contraindications to labor induction? Select all that apply.
- A. Umbilical cord prolapse
- B. Transverse fetal lie
- C. Cervical dilation not progressing
- D. Premature rupture of membranes
- E. Previous cesarean incision
Correct Answer: A,B,E
Rationale: Inducing labor with an umbilical cord prolapsed can cause fetal trauma and is contraindicated. This should be reported to the HCP. Inducing labor with a transverse fetal lie can produce trauma to the fetus and mother and is contraindicated. This should be reported to the HCP. Women with a previous cesarean incision should not be stimulated because it is a contraindication for a vaginal birth and warrants an immediate repeat cesarean birth. This should be reported to the HCP. Lack of progressive cervical dilation is an indication for labor induction, not a contraindication. Premature rupture of the membranes is an indication for labor induction, not a contraindication.
Which advice can the nurse give to relieve the client's backache? Select all that apply.
- A. Avoid clothing that fits tightly around the waist.
- B. Sleep on a heating pad.
- C. Take a nonopioid pain reliever regularly.
- D. Wear low-heeled shoes.
- E. Carry objects close to your body.
- F. Squat when picking objects off the floor.
Correct Answer: A,D,E,F
Rationale: Tight clothing, high heels, and improper lifting exacerbate backaches; low-heeled shoes, proper lifting, and loose clothing help relieve strain.
The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
- A. Client who is 2 hours post-cesarean birth for a breech baby
- B. Client who delivered a macrosomic baby after a 12-hour labor
- C. Client who has a firm fundus after a vaginal delivery 4 hours ago
- D. Client receiving oxytocin intravenously for past 2 hours
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.