Nokea
What is the primary purpose of administering vitamin K to a newborn?
- A. Prevent anemia
- B. Enhance immune function
- C. Prevent bleeding disorders
- D. Promote growth and development
Correct Answer: C
Rationale: Newborns are born with low levels of vitamin K, essential for blood clotting.
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The nurse is monitoring a client who is 34 weeks ges- dividing?
- A. Trophoblast or inner cell mass that becomes the fetal monitor tracing are a priority for the nurse to placenta
- B. Embryoblast or inner cell mass that becomes the that apply. embryo
- C. Baseline FHR 140, accelerations, late decelerations,
- D. Morula
Correct Answer: A
Rationale: In the context of the question, the nurse is monitoring a 34-week gestation client. At 34 weeks, the trophoblast or inner cell mass has already developed into the placenta, which is formed earlier in pregnancy. Therefore, choice A is the most relevant option in this scenario. Trophoblast is critical for implantation and the formation of the placenta, which plays a vital role in supporting the developing fetus by providing oxygen and nutrients. Understanding the different stages of fetal development can help the nurse provide optimal care and monitor for any potential issues that may arise during pregnancy.
A client at 36 weeks' gestation reports decreased fetal movement. What is the nurse's priority action?
- A. Perform a nonstress test.
- B. Encourage the client to drink orange juice.
- C. Schedule an ultrasound.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: A nonstress test evaluates fetal well-being and is the first step in assessing decreased fetal movement.
A client in the third trimester reports severe itching without rash. What condition should the nurse suspect?
- A. Cholestasis of pregnancy.
- B. Preeclampsia.
- C. Gestational diabetes.
- D. Fungal infection.
Correct Answer: A
Rationale: Severe itching in pregnancy without a rash is commonly associated with cholestasis of pregnancy.
A client in labor reports sudden pain and bright red vaginal bleeding. What should the nurse suspect?
- A. Placenta previa.
- B. Abruptio placentae.
- C. Preterm labor.
- D. Rupture of membranes.
Correct Answer: B
Rationale: Bright red bleeding and sudden pain suggest abruptio placentae, requiring urgent intervention.
A nurse is assessing a newborn who is 48 hours old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to substances, such as methadone, while in the womb. Infants with NAS may exhibit excessive high-pitched crying as one of the manifestations. Other common symptoms of NAS include irritability, tremors, feeding difficulties, sweating, fever, vomiting, diarrhea, and poor weight gain. Therefore, in this case, the excessive high-pitched cry is a manifestation that the nurse should identify as an indication of neonatal abstinence syndrome.