Nokea
Twenty-four hours after cesarean delivery, a neonate at 30 weeks' gestation is diagnosed with respiratory distress syndrome (RDS). When explaining to the parents about the cause of this syndrome, the nurse should include a discussion about an alteration in the body's secretion of which of the following?
- A. Somatotropin.
- B. Surfactant.
- C. Testosterone.
- D. Progesterone.
Correct Answer: B
Rationale: RDS is caused by insufficient surfactant production, which is critical for lung expansion and preventing alveolar collapse.
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After teaching a primiparous client who used cocaine during pregnancy about possible gastrointestinal signs and symptoms in her neonate, which of the following, if stated by the mother as common, indicates effective teaching?
- A. Hypotonia.
- B. Constipation.
- C. Vomiting.
- D. Abdominal distention.
Correct Answer: C
Rationale: Vomiting is a common gastrointestinal symptom in neonates with cocaine exposure due to neurological irritability.
A 28-year-old multigravid client at 28 weeks' gestation diagnosed with acute pyelonephritis is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following?
- A. Preterm labor.
- B. Maternal sepsis.
- C. Intrauterine growth retardation.
- D. Congenital fetal anomalies.
Correct Answer: D
Rationale: Acute pyelonephritis can cause preterm labor, maternal sepsis, and intrauterine growth retardation due to infection and inflammation. Congenital fetal anomalies are not a direct consequence, indicating a need for further teaching.
The nurse has obtained a urine specimen from a G 6, P 5 client admitted to the labor unit. The woman asks to go to the bathroom and reports that she feels she has to move her bowels. Which actions would be appropriate? Select all that apply.
- A. Assisting her to the bathroom.
- B. Applying an external fetal monitor to obtain fetal heart rate.
- C. Assessing her stage of labor.
- D. Asking if she had back labor pains like this with any of her other deliveries.
- E. Allowing her support person to take her to the bathroom to maintain privacy.
- F. Checking the degree of fetal descent.
Correct Answer: C,F
Rationale: The urge to move bowels often indicates advanced labor or fetal descent in a multiparous client. Assessing the stage of labor and fetal descent (via vaginal exam) confirms progression and prevents unattended delivery. Assisting to the bathroom or relying on a support person risks delivery, and fetal monitoring or past labor history are secondary.
A client with pregnancy-induced hypertension is to receive magnesium sulfate to run at 3 grams per hour with normal saline to maintain the total I.V. rate at 125 mL/hour. The nurse giving end of shift report stated the client's blood pressures have been elevated during the night. The oncoming nurse checked the client and found magnesium sulfate running at 2 grams per hour. Identify the nursing actions to be taken from first to last.
- A. Correct the I.V. rates to magnesium sulfate running at 3 grams/hour and normal saline to complete total rate at 125 mL/hour.
- B. Initiate an incident report.
- C. Assess the client's current status.
- D. Notify the physician of the incident.
Correct Answer: C,A,D,B
Rationale: Assess the client first, correct the error, notify the physician, and then document the incident.
After instruction of a primigravid client at 8 weeks' gestation about measures to overcome early morning nausea and vomiting, which of the following client statements indicates the need for additional teaching?
- A. "I'll eat dry crackers or toast before arising in the morning."
- B. "I'll drink adequate fluids separate from my meals or snacks."
- C. "I'll eat two large meals daily with frequent protein snacks."
- D. "I'll snack on a small amount of carbohydrates throughout the day."
Correct Answer: C
Rationale: Two large meals may worsen nausea; smaller, more frequent meals are recommended.