Nokea
A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of less than 90
- C. Creases over the entire sole
- D. Sparse lanugo
Correct Answer: B
Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.
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The nurse is monitoring a pregnant client with suspected gestational hypertension. What finding confirms the diagnosis?
- A. Proteinuria.
- B. Blood pressure of 140/90 mmHg on two occasions.
- C. Edema of the hands and feet.
- D. Elevated blood glucose levels.
Correct Answer: B
Rationale: Gestational hypertension is diagnosed by consistent readings of 140/90 mmHg or higher without proteinuria.
A pregnant client reports frequent urination and lower abdominal pressure at 36 weeks. What should the nurse explain?
- A. This is a sign of preterm labor.
- B. This indicates urinary tract infection.
- C. This is common due to fetal descent.
- D. This is caused by Braxton Hicks contractions.
Correct Answer: C
Rationale: As the fetus descends into the pelvis (lightening), increased pressure on the bladder causes frequent urination.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Administer a pneumococcal immunization to the newborn within 4 hr. following birth.
- D. Bathe the newborn before initiating skin-to-skin contact
Correct Answer: C
Rationale: Administering a pneumococcal immunization to the newborn within 4 hours following birth is a crucial action to include in the plan of care for a pregnant client with HIV. Infants born to HIV-positive mothers are at higher risk for infections, including pneumococcal disease. Administering a pneumococcal vaccine shortly after birth helps protect the newborn from this serious infection. It is important to follow established guidelines for immunizations in newborns of HIV-positive mothers to optimize the infant's health outcomes.
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.
What emergency contraception has the best efficacy for prevention of pregnancy?
- A. Plan B
- B. Yuzpe
- C. copper IUC
- D. progesterone-only EC
Correct Answer: C
Rationale: Copper intrauterine devices (IUDs) have the best efficacy for prevention of pregnancy among emergency contraception options. Copper IUDs are over 99% effective when used as emergency contraception, making them more reliable than other methods like Plan B, Yuzpe, or progesterone-only EC. This high efficacy is due to the mechanism of action of copper IUDs, which prevent fertilization and implantation of the fertilized egg. Additionally, once inserted, a copper IUD can continue to provide ongoing contraception for up to 10 years, making it a long-term contraceptive option as well.