Nokea
The physician has determined the need for forceps. The nurse should explain to the patient that the need for forceps is indicated because
- A. Premature placental separation (also used for prolapsed cord and nonreasoning fetal HR)
- B. Her support person is exhausted
- C. To shorten the first stage of labor
- D. To prevent fetal distress
Correct Answer: A
Rationale: Forceps delivery is indicated in situations where there is fetal distress due to premature placental separation or nonreassuring fetal heart rate. Forceps are used to facilitate a quicker delivery and reduce the risk to the baby during such emergency situations. Forces are also used in cases of fetal distress due to a prolapsed cord where a quick delivery is necessary to relieve pressure on the umbilical cord.
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On examination the hands and feet of a 6 hours old infant is cyanotic without signs of distress. The nurse should document these findings as:
- A. Potential for respiratory distress
- B. Poor oxygenation
- C. Cold stress
- D. Acrocyanosis
Correct Answer: D
Rationale: Acrocyanosis is a condition commonly seen in newborns where the hands and feet appear blue or purple in color due to decreased circulation in the peripheral blood vessels. It is usually a normal finding in newborns and is not associated with distress or poor oxygenation. Unlike central cyanosis which indicates a more serious underlying issue affecting oxygen levels in the blood, acrocyanosis is a benign and self-limiting condition. It is important for the nurse to recognize and document acrocyanosis to differentiate it from other potentially concerning conditions.
The nurse is assessing a client with suspected ectopic pregnancy. What is the most common symptom?
- A. Bright red vaginal bleeding.
- B. Severe lower abdominal pain.
- C. Increased fetal movement.
- D. Painless vaginal spotting.
Correct Answer: B
Rationale: Severe lower abdominal pain, often on one side, is a hallmark symptom of ectopic pregnancy.
Which newborn reflex is assessed by stroking the cheek?
- A. Startle reflex
- B. Rooting reflex
- C. Babinski reflex
- D. Sucking reflex
Correct Answer: B
Rationale: The rooting reflex is observed when stroking the cheek, helping the newborn find the breast for feeding.
How should a nurse educate a mother about kangaroo care for her preterm infant?
- A. Encourage frequent visits to the NICU
- B. Educate about skin-to-skin contact benefits
- C. Explain the importance of bonding
- D. Teach the mother about safe handling of the newborn
Correct Answer: B
Rationale: Kangaroo care promotes bonding and regulates temperature for preterm infants.
The nurse is monitoring a client in labor who is receiving oxytocin. What finding requires immediate intervention?
- A. Contractions lasting 90 seconds.
- B. Contractions every 2–3 minutes.
- C. Fetal heart rate of 100 beats/minute.
- D. Maternal heart rate of 85 beats/minute.
Correct Answer: C
Rationale: A fetal heart rate of 100 bpm indicates bradycardia, which may signify fetal distress and requires immediate action.