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A nurse is caring for a client who is receiving prenatal care and is at her 24- week appointment. Which of the following laboratory tests should the nurse plans to conduct?
- A. Group B strep culture
- B. 1-hr glucose tolerance test
- C. Rubella titer
- D. Blood type and Rh
Correct Answer: D
Rationale: At the 24-week prenatal appointment, it is essential to conduct the blood type and Rh test for the pregnant client. Determining the mother's blood type (A, B, AB, O) and Rh factor (positive or negative) is crucial as it helps identify if the mother is Rh-negative and at risk for Rh incompatibility with her baby. This information is vital for appropriate management to prevent potential complications such as hemolytic disease of the newborn. Conducting the blood type and Rh test at this stage allows healthcare providers to take necessary precautions to protect both the mother and the fetus.
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A nurse is assessing a newborn who was born vaginally with vacuum extractor assistance ... that crosses the suture line. The nurse should identify the swellings as which of the following....?
- A. Nevus flammeus
- B. Caput uccedaneum
- C. Cephalohematoma
- D. Erythema toxicum
Correct Answer: C
Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.
The nurse is caring for a client at 39 weeks' gestation in active labor. The fetal monitor shows late decelerations. What is the priority nursing action?
- A. Reposition the client to her left side.
- B. Increase the oxytocin infusion rate.
- C. Encourage the client to push harder.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Repositioning improves uteroplacental blood flow and oxygen delivery to the fetus, addressing late decelerations.
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.
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.