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A nurse is caring for four clients. For which of the following clients should the nurse auscultate the fetal heart rate during the prenatal visit?
- A. A client who has an ultrasound that confirms a molar pregnancy
- B. A client who has a crown-rump length of 7 weeks gestation
- C. A client who has a positive urine pregnancy test 1 week after missed menses
- D. A client who has felt quickening for the first time
Correct Answer: D
Rationale: The correct answer is D. The nurse should auscultate the fetal heart rate for a client who has felt quickening for the first time during the prenatal visit. Quickening is the first fetal movements felt by the mother, typically occurring around 18-20 weeks gestation. Auscultating the fetal heart rate confirms the presence of fetal life and ensures the fetus is developing appropriately. This step is crucial in assessing fetal well-being and monitoring for any potential complications.
Choice A: A client with a molar pregnancy does not have a viable fetus; auscultating the fetal heart rate is not necessary.
Choice B: A client with a crown-rump length of 7 weeks gestation may be too early for fetal heart rate detection using auscultation.
Choice C: A positive urine pregnancy test alone does not indicate fetal viability; auscultation is needed to assess the fetus.
In summary, choice D is correct as it aligns with the timing of fetal movement and the need to assess
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A nurse is reviewing the laboratory results for a newborn 12 hours old. Which of the following is an expected findings.
- A. Glucose 40mg/dl
- B. WBC 6000
- C. Hemoglobin 12
- D. Platelets 80000
Correct Answer: A
Rationale: The correct answer is A: Glucose 40mg/dl. In newborns, normal glucose levels range from 40-60mg/dl. This level is expected to be lower in the immediate postnatal period due to the transition from placental to independent glucose regulation. WBC count of 6000 is within normal range. Hemoglobin at 12 is normal for a newborn. Platelets of 80000 are low and could indicate a potential issue, such as thrombocytopenia, which would require further investigation.
A nurse is assessing a newborn immediately following a vaginal birth. For which of the following findings should the nurse intervene?
- A. Molding
- B. Vernix Caseosa
- C. Acrocyanosis
- D. Sternal retractions
Correct Answer: D
Rationale: The correct answer is D: Sternal retractions. Sternal retractions in a newborn indicate respiratory distress, potentially due to a blocked airway or difficulty breathing. The nurse should intervene immediately to ensure the newborn's airway is clear and that they are able to breathe properly.
A: Molding is the overlapping of cranial bones during birth, a common and temporary finding.
B: Vernix Caseosa is a protective coating on the newborn's skin and is normal.
C: Acrocyanosis is the bluish discoloration of the hands and feet, a common finding in newborns due to immature circulation.
A nurse is planning care for a client who is pregnant and has HIV.
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin-to-skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin-to-skin contact. This is because bathing the newborn before skin-to-skin contact helps reduce the risk of HIV transmission from mother to baby. HIV can be present in maternal blood and other fluids, and washing the newborn can decrease the viral load on the baby's skin. Initiating skin-to-skin contact without bathing first may increase the risk of transmission.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to baby. Choice C is incorrect as stopping antiretroviral medication can be harmful to both the mother and the baby's health. Choice D is incorrect as pneumococcal immunization is not recommended within 4 hours following birth and is not directly related to HIV transmission prevention.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn’s temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. This is because lotions or ointments can interfere with the effectiveness of phototherapy by blocking the light from reaching the skin. Dressing the newborn in lightweight clothing (Choice A) is important to maximize skin exposure to the light. Keeping the newborn supine throughout treatment (Choice C) is not directly related to the effectiveness of phototherapy. Measuring the newborn's temperature every 8 hours (Choice D) is important but not specifically related to phototherapy.
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.