Nokea
What is the first step the nurse should take when assessing a newborn's respiratory status immediately after birth?
- A. observe for respiratory effort
- B. take the newborn's temperature
- C. assist with suctioning the airways
- D. suction the newborn's mouth
Correct Answer: A
Rationale: The correct answer is A: observe for respiratory effort. This is the first step because it helps the nurse quickly assess if the newborn is breathing effectively. Observing for respiratory effort allows for prompt identification of any potential respiratory distress or abnormalities. Taking the newborn's temperature (B) is important but not the first step in assessing respiratory status. Assisting with suctioning the airways (C) should only be done if there are signs of airway obstruction, not as the initial step. Suctioning the newborn's mouth (D) is not recommended immediately after birth unless there is clear obstruction, as this can stimulate unnecessary reflexes and cause harm.
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The nurse takes the history of a client, G2 P1001, at her first prenatal visit. Which of the following statements would indicate that the client should be referred to a genetic counselor?
- A. My first child has cerebral palsy.
- B. My first child has hypertension.
- C. My first child has asthma.
- D. My first child has cystic fibrosis.
Correct Answer: D
Rationale: Cystic fibrosis is a genetic condition, and a history of it in a previous child would warrant a referral to a genetic counselor. Cerebral palsy, hypertension, and asthma are not typically genetic conditions.
A nurse is caring for a postpartum person who is at risk for postpartum hemorrhage. What is the most important nursing action to reduce the risk?
- A. administer oxytocin
- B. administer IV fluids
- C. administer an epidural
- D. perform fundal massage
Correct Answer: B
Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate circulating volume, preventing hypovolemia which is a major risk factor for postpartum hemorrhage. This action supports blood pressure and perfusion to reduce the risk of excessive bleeding. Administering oxytocin (A) helps with uterine contraction but does not address the underlying issue of hypovolemia. Administering an epidural (C) is not directly related to preventing postpartum hemorrhage. Fundal massage (D) is important but not the most critical action in reducing the risk of postpartum hemorrhage.
The clinic nurse is obtaining a health history on a newly pregnant patient. Which is an indication for fetal diagnostic procedures if present in the health history?
- A. Maternal diabetes
- B. Weight gain of 25 lb
- C. Maternal age older than 30 years
- D. Previous infant weighing more than 3000 g at birth
Correct Answer: A
Rationale: Maternal diabetes is a risk factor in pregnancy due to possible impairment of placental perfusion, necessitating fetal diagnostic procedures.
A nurse is providing prenatal education to a pregnant patient. Which of the following statements indicates a need for further teaching about maternal weight gain during pregnancy?
- A. I should aim to gain about 25 to 35 pounds during my pregnancy.
- B. I should eat for two during pregnancy.
- C. I can exercise as long as I stay within my doctor's recommendations.
- D. Gaining too much weight during pregnancy can increase my risk of complications.
Correct Answer: B
Rationale: The correct answer is B because the statement "I should eat for two during pregnancy" is incorrect. The rationale is that during pregnancy, a woman does not need to eat for two individuals. Instead, she needs to consume additional calories to support the growth and development of the fetus. Eating for two could lead to excessive weight gain and potential complications. The other choices indicate correct understanding and knowledge about maternal weight gain during pregnancy. A suggests the recommended weight gain range, C acknowledges the importance of exercising within doctor's limits, and D highlights the risks of gaining too much weight during pregnancy.
A multigravid client is 22 weeks pregnant. Which of the following symptoms would the nurse expect the client to exhibit?
- A. Nausea.
- B. Dyspnea.
- C. Urinary frequency.
- D. Leg cramping.
Correct Answer: D
Rationale: Leg cramping is a common complaint during the second trimester. Nausea is more common in the first trimester, and dyspnea and urinary frequency are more common in the third trimester.