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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.
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The nurse is preparing a client for a nonstress test. What instruction should the nurse provide?
- A. Avoid eating or drinking before the test.
- B. Press the button whenever you feel the baby move.
- C. Lie flat on your back during the test.
- D. Expect contractions to occur during the test.
Correct Answer: B
Rationale: The client should press the button when fetal movements are felt, which are correlated with fetal heart rate accelerations.
Which contraceptive method is best for a woman with multiple sex partners?
- A. Intrauterine device.
- B. Female condom.
- C. Bilateral tubal ligation.
- D. Birth control pills.
Correct Answer: B
Rationale: Female condoms provide dual protection against pregnancy and STIs.
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.
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning the woman9s care. The nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus due to the GDM. The nurse identifies that the fetus is at risk for which of the following? Congenital anomalies of the central nervous system Macrosomia Preterm birth Low birth weight Screening at 24 weeks of gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care, the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. The nurse identifies that the fetus is at greatest risk for:
- A. macrosomia.
- B. congenital anomalies of the central nervous system.
- C. preterm birth.
- D. low birth weight. A
Correct Answer: A
Rationale: Gestational diabetes mellitus (GDM) is a condition where high blood sugar levels develop during pregnancy in women who didn't have diabetes before pregnancy. One of the primary risks associated with GDM is fetal overgrowth, also known as macrosomia. This means the baby is larger than normal. Macrosomia can lead to complications during delivery, such as shoulder dystocia (when the baby's shoulders get stuck during delivery) and an increased risk of birth injuries for both the baby and the mother. It can also increase the likelihood of a cesarean section delivery. Therefore, preventing macrosomia is an important goal in managing GDM to ensure the safety and well-being of both the mother and the baby.
Which signs/symptoms would the nurse expect to see in a client diagnosed with pubic lice?
- A. Macular rash on the labia.
- B. Pruritus.
- C. Hyperthermia.
- D. Foul-smelling discharge.
Correct Answer: B
Rationale: Itching (pruritus) is a hallmark symptom of pubic lice infestation.