Nokea
The nurse is making clinical rounds on a group of clients in a newborn nursery. Which infant is at greatest risk of developing respiratory distress syndrome (RDS)?
- A. A neonate born at 36 weeks' gestation.
- B. A neonate born by Cesarean section.
- C. A neonate experiencing apneic episodes.
- D. A neonate who is 42 weeks' gestation.
Correct Answer: C
Rationale: A neonate experiencing apneic episodes is at greatest risk for RDS due to compromised respiratory function.
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While assessing a primigravid client admitted at 36 weeks' gestation, the nurse observes multiple bruises on the client's face, neck, and abdomen. When asked about the bruises, the client admits that her boyfriend beats her now and then and says, 'I want to leave him because I'm afraid he will hurt the baby.' Which of the following actions is the nurse's priority?
- A. Tell the client to leave the boyfriend immediately.
- B. Ask the client when she last felt the baby move.
- C. Refer the client to a social worker for possible options.
- D. Report the incident to the unit nursing supervisor.
Correct Answer: C
Rationale: Suspected domestic violence requires referral to a social worker to provide resources (e.g., shelters, counseling) and ensure maternal-fetal safety. Advising immediate leaving is impractical, fetal movement assessment is secondary, and reporting to the supervisor does not directly help the client.
After reinforcing the danger signs to report with a gravida 2 client at 32 weeks' gestation with an elevated blood pressure, which client statements would demonstrate her understanding of when to call the physician's office? Select all that apply.
- A. "If I get up in the morning and feel dizzy, even if the dizziness goes away."
- B. "If I see any bleeding, even if I have no pain."
- C. "If I have a pounding headache that doesn't go away."
- D. "If I notice the veins in my legs getting bigger."
- E. "If the leg cramps at night are waking me up."
- F. "If the baby seems to be more active than usual."
Correct Answer: A,B,C,F
Rationale: These symptoms could indicate complications needing medical attention.
Assessment of a primigravid client reveals cervical dilation at 8 cm and complete effacement. The client complains of severe back pain during this phase of labor. The nurse explains that the client's severe back pain is most likely caused by the fetal occiput being in a position that is identified as which of the following?
- A. Breech.
- B. Transverse.
- C. Posterior.
- D. Anterior.
Correct Answer: C
Rationale: Severe back pain in labor is commonly associated with a posterior occiput position (e.g., occipitoposterior), where the fetal head presses against the maternal sacrum. Breech, transverse, or anterior positions are less likely to cause intense back pain.
Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?
- A. Wait until you have breast-fed for at least 4 months.
- B. Eliminate the baby's favorite feeding times first.
- C. Plan to omit the daytime feedings last.
- D. Gradually eliminate one feeding at a time.
Correct Answer: D
Rationale: Gradual weaning by eliminating one feeding at a time minimizes discomfort and distress for both mother and baby.
For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:
- A. Exhaustion.
- B. Chills and fever.
- C. Fluid overload.
- D. Meconium-stained fluid.
Correct Answer: A
Rationale: Prolonged latent phase (8 hours) in a primigravid client can lead to maternal exhaustion due to sustained effort and lack of progress, impacting labor stamina. Chills/fever, fluid overload, or meconium-stained fluid are less likely without specific risk factors.