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Three hours after birth, a newborn of a mother with diabetes becomes jittery, has weak, high- pitched cry , and exhibits irregular respirations. The nurse recognizes that these signs are often associated with:
- A. Hypovolemia
- B. Hypocalcemia
- C. Hypoglycemia
- D. Hyperglycemia
Correct Answer: C
Rationale: The signs described in the scenario - jitteriness, weak high-pitched cry, irregular respirations - are indicative of hypoglycemia in a newborn. Babies born to mothers with diabetes are at risk for hypoglycemia due to their exposure to high blood sugar levels in utero. After birth, when the baby is separated from the mother's blood supply, their own insulin production may lead to a sudden drop in blood glucose levels.
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A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency
- B. Maternal bradycardia
- C. Umbilical cord compression
- D. Fetal head compression
Correct Answer: A
Rationale: Late decelerations on the fetal monitor strip indicate uteroplacental insufficiency. These decelerations occur after the peak of a contraction, and the fetus may not receive enough oxygen-rich blood during contractions. Uteroplacental insufficiency can lead to fetal hypoxia and acidosis if not addressed promptly. It is important for the nurse to take appropriate steps to improve fetal oxygenation, such as repositioning the mother, administering oxygen, and adjusting IV fluids. If late decelerations persist, further interventions may be necessary to ensure the well-being of the fetus.
How should a nurse assess for proper latch during breastfeeding?
- A. Ensure the baby's nose is covered during feeding
- B. Ensure the baby's lips are sealed around the areola
- C. Check for audible swallowing during feeding
- D. Encourage frequent feeding attempts
Correct Answer: B
Rationale: Ensuring the baby's lips are sealed around the areola promotes effective milk transfer and reduces pain.
A client at 12 weeks' gestation complains of nausea. What dietary advice should the nurse provide?
- A. Eat three large meals a day.
- B. Avoid drinking fluids between meals.
- C. Increase intake of spicy foods.
- D. Consume high-fat snacks frequently.
Correct Answer: B
Rationale: Avoiding fluids during meals can help reduce nausea by minimizing gastric distension.
A 28-year-old patient has decided to use the patch contraception. The nurse is educating her on the best site to use. Where is the best place to put the patch? Select one that does not that apply.
- A. Buttocks
- B. Leg
- C. Breast
- D. Arm
Correct Answer: C
Rationale: The best sites for applying the contraceptive patch are the buttocks, arm, and leg. These areas have sufficient fat and are away from areas that might rub off the patch. Choice B (Neck) is incorrect as the neck is not recommended for patch application due to the potential for irritation and the high blood flow area. Choice C (Breast) is not recommended because the breast tissue may affect the adhesion of the patch.
What organization developed the CJMM?
- A. ACOG
- B. ANA
- C. AWHONN
- D. NCSBN
Correct Answer: C
Rationale: The organization that developed the CJMM is the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The CJMM, which stands for Core JMM, is a framework used for assessing labor progress during childbirth. AWHONN is a professional association that focuses on promoting the health of women and newborns, and they are widely recognized for their work in developing standards and guidelines in the field of obstetric and neonatal nursing.