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What is the nurse's first action for a newborn showing signs of hypoglycemia?
- A. Feed the newborn formula immediately
- B. Encourage breastfeeding or formula feeding
- C. Monitor glucose levels every hour
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: The correct answer is A: Feed the newborn formula immediately. The first action for a newborn showing signs of hypoglycemia is to provide them with a source of glucose to raise their blood sugar levels quickly. Formula feeding is an effective way to achieve this as it provides a concentrated source of glucose. Encouraging breastfeeding or formula feeding (choice B) is a good option but may not address the immediate need for glucose. Monitoring glucose levels every hour (choice C) is important but not the first action to take in an acute situation. Notifying the healthcare provider immediately (choice D) is necessary but should come after addressing the immediate need for glucose.
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A client at 30 weeks' gestation is receiving magnesium sulfate for preterm labor. What assessment finding indicates magnesium toxicity?
- A. Deep tendon reflexes +3.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 40 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. Magnesium sulfate toxicity can lead to respiratory depression, resulting in a decreased respiratory rate. This is a critical sign of magnesium toxicity and should be addressed promptly.
Explanation for other choices:
A: Deep tendon reflexes +3 are actually a common finding in clients receiving magnesium sulfate due to its muscle relaxant effects.
C: Urine output of 40 mL/hour is within the normal range and does not indicate magnesium toxicity.
D: Blood pressure of 120/80 mmHg is also within the normal range and is not a sign of magnesium toxicity.
The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.
What is the best position for a laboring mother with a suspected occiput posterior position?
- A. Encourage side-lying position
- B. Place the mother in lithotomy position
- C. Encourage ambulation to facilitate descent
- D. Use a peanut ball to widen the pelvis
Correct Answer: D
Rationale: The correct answer is D. Using a peanut ball widens the pelvis, which can help rotate the baby into an optimal position for birth. This position can aid in reducing the likelihood of prolonged labor and the need for interventions. Encouraging side-lying position (A) may not provide the necessary pelvic widening. Placing the mother in lithotomy position (B) can impede the baby's descent. Encouraging ambulation (C) may not specifically address the occiput posterior position and may not provide enough pelvic opening.
The nurse is preparing a client for a biophysical profile (BPP). What does this test evaluate?
- A. Maternal blood flow to the placenta.
- B. Fetal genetic abnormalities.
- C. Fetal well-being, including movements and amniotic fluid.
- D. Cervical dilation and effacement.
Correct Answer: C
Rationale: The correct answer is C: Fetal well-being, including movements and amniotic fluid. A Biophysical Profile evaluates the fetus' health by assessing factors like fetal movements, muscle tone, breathing movements, amniotic fluid volume, and fetal heart rate patterns. This test provides valuable information about the fetus' well-being and helps in determining the need for interventions or further monitoring.
Explanation of why the other choices are incorrect:
A: Maternal blood flow to the placenta is not evaluated by a Biophysical Profile.
B: Fetal genetic abnormalities are not assessed through a BPP; it focuses on the fetus' current well-being.
D: Cervical dilation and effacement are related to labor progress and not part of a BPP, which focuses on fetal well-being.
The nurse is teaching the postpartum client about newborn transitional stool. Which should the nurse include in the teaching session? SATA
- A. They have greenish brown color
- B. They are looser consistency
- C. They are seedy with sweet sour smell
- D. They have tar like consistency
Correct Answer: A
Rationale: The correct answer is A because transitional stools in newborns typically have a greenish-brown color due to the presence of meconium and the changing composition of the stool as the baby starts digesting breastmilk or formula.
Rationale:
1. A: Greenish-brown color is characteristic of transitional stools as meconium is being passed out.
Incorrect answers:
2. B: Transitional stools are not necessarily looser in consistency.
3. C: Transitional stools are not typically described as seedy with a sweet-sour smell.
4. D: Tar-like consistency is more indicative of meconium, not transitional stools.