Nokea
The nurses assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indication that the infant is transitioning well to extrauterine life?
- A. Heart rate 220 beats/minute
- B. Cries vigorously when stimulated
- C. A positive Babinski reflex
- D. Flexion of all four extremities
Correct Answer: B
Rationale: Vigorous crying (B) indicates effective transition to extrauterine life.
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A client who is anovulatory and has hyperprolactinemia is being treated for infertility with metformin, menotropins (Repronex, MENOPUR®), and human chorionic gonadotropin(hCG). Which side effects should the nurse tell the client to report immediately?
- A. Episodes of headache and irritability
- B. Nausea and vomiting
- C. Rapid increase in abdominal girth
- D. Persistent daytime fatigue
Correct Answer: C
Rationale: Rapid abdominal girth increase (C) may indicate ovarian hyperstimulation syndrome, a serious complication.
When assessing a pregnant woman AT 39-weeks gestation who is admitted to labor and delivery which finding is most important to report to the health care provider?
- A. proteinuria
- B. 130/70 blood pressure
- C. pedal edema
- D. 101.2 oral temperature
Correct Answer: D
Rationale: Fever (D) can indicate infection, which requires prompt evaluation.
Expectant parents ask a prenatal nurse educator, 'Which setting for childbirth limits the amount of parent-infant interaction?'
- A. Birth center
- B. Home birth
- C. Traditional hospital birth
- D. Labor, birth, and recovery room
Correct Answer: C
Rationale: In traditional hospital settings, the mother may see the infant for only short feeding periods, and the infant is cared for in a separate nursery.
The healthcare provides prescribes 10 units/L of oxytocin (Pitocin) via IV drips to augment a client labor because she is experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin?
- A. Uterus soft
- B. Contraction duration of 100 seconds
- C. Four contractions in 10 minutes
- D. Early deceleration of fetal heart rate
Correct Answer: B
Rationale: Contractions lasting longer than 90 seconds (B) can compromise fetal oxygenation and require discontinuing oxytocin.
Which step of the nursing process is being used when the nurse decides whether an ethical dilemma exists?
- A. Analysis
- B. Planning
- C. Evaluation
- D. Assessment
Correct Answer: A
Rationale: Deciding whether an ethical dilemma exists involves analyzing collected data to determine if conflicting values or principles are present.