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The nurse would classify a newborn delivered at 39 weeks' gestation, weighing 2400 g ( 5.0 lbs) as being:
- A. Preterm and immature
- B. Small-for-gestational age
- C. Average-for-gestational age
- D. Average-for-gestational age but pre-term
Correct Answer: B
Rationale: Weight below the 10th percentile indicates small-for-gestational age.
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A client at 32 weeks' gestation is experiencing preterm labor. What is the primary goal of tocolytic therapy?
- A. To prevent fetal hypoxia.
- B. To delay delivery and improve fetal lung maturity.
- C. To reduce maternal blood pressure.
- D. To increase uteroplacental blood flow.
Correct Answer: B
Rationale: Tocolytics are used to delay preterm delivery, allowing time for fetal lung maturity with corticosteroid administration.
What should be included in teaching a client undergoing a bilateral tubal ligation?
- A. The surgical procedure is easily reversible.
- B. Menstruation usually ceases after the procedure.
- C. Libido should remain the same after the procedure.
- D. The incision will be made endocervically.
Correct Answer: C
Rationale: Tubal ligation does not affect libido.
The nurse's initial action when caring for an infant with a slightly decreased temperature is to:
- A. notify the physician immediately.
- B. place a cap on the infant's head and have the mother perform kangaroo care.
- C. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours.
- D. change the formula, as this is a sign of formula intolerance.
Correct Answer: B
Rationale: Kangaroo care and covering the head help conserve heat.
A nurse receives report about assigned clients at the start of the shift. Which of the following clients should the nurse plan to see first?
- A. A client who experienced a cesarean birth 4 hr ago and reports pain
- B. A client who has preeclampsia with a BP of 138/90 mm Hg
- C. A client who experienced a vaginal birth 24 hr ago and reports no bleeding
- D. A client who is scheduled for discharge following a laparoscopic tubal ligation Which of the following findings indicates that it is safe for the nurse to continue the infusion? .
Correct Answer: A
Rationale: The client who experienced a cesarean birth 4 hours ago and is reporting pain should be seen first by the nurse. Pain assessment and management are crucial following a cesarean birth to ensure the client's comfort and well-being. Uncontrolled pain can lead to complications and affect the client's recovery process. Addressing the client's pain promptly is a priority to promote their comfort and facilitate their recovery.
What actions should the nurse advise women to take when educating them on breast self-examination (BSE)?
- A. Use the fingertips of their index, middle, and ring fingers.
- B. Use pressure in two intensities, light and deep.
- C. Look for dimpling while bending forward from the waist.
- D. Feel for lumps while encircling the breast from nipple outward.
Correct Answer: A
Rationale: Proper technique ensures accurate detection of abnormalities.