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The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?
- A. Flaring of the nares
- B. Shallow and irregular respirations
- C. Respiratory rate of 50 breaths per minute
- D. Abdominal breathing with synchronous chest movement
Correct Answer: A
Rationale: Flaring of the nares is a specific sign of respiratory distress in newborns, indicating increased effort to breathe. It is more immediate and specific than other options.
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The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.
A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Inspect the client's face for edema
- B. Ascertain the frequency of headaches
- C. Evaluate for history of cluster headaches
- D. Observe and time client's contractions
Correct Answer: A
Rationale: Elevated blood pressure at 32 weeks may suggest preeclampsia. Inspecting for facial edema is a priority to assess for fluid retention, a key sign of this condition.
The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?
- A. Explain reasons consent for an infant autopsy is needed
- B. Determine if the mother desires a visit from her clergy
- C. Encourage the mother to hold and spend time with her baby
- D. Create a memory box of baby's footprints and photographs
Correct Answer: C
Rationale: Encouraging the mother to hold and spend time with her baby supports the grieving process, helping her acknowledge and create memories with her child.
Which type of anesthesia, used with a client in labor, produces a loss of sensation only to the vagina and perineum?
- A. Epidural block
- B. Saddle block
- C. Paracervical block.
- D. Pudendal block
Correct Answer: D
Rationale: A pudendal block targets the pudendal nerve, numbing only the vagina and perineum, making it ideal for the second stage of labor.
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?
- A. The diaphragm must be refitted after childbirth
- B. The most effective form of contraception is a diaphragm
- C. The diaphragm should be inserted 2 to 4 hours before intercourse.
- D. Vaseline lubricant can be used when inserting the diaphragm
Correct Answer: A
Rationale: Childbirth can alter vaginal and cervical anatomy, requiring the diaphragm to be refitted for effective contraception.