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What tion in the FHR that is abrupt and appears to be does the nurse inform this group that they are at in the shape of a W. What is the most likely cause highest risk for? of this?
- A. Sexually transmitted diseases
- B. Compression of the fetal head
- C. Uterine cancer
- D. Compression of the umbilical cord
Correct Answer: D
Rationale: An abnormality in the FHR that is abrupt and appears to be in the shape of a "W" is often indicative of variable decelerations. Variable decelerations typically occur due to compression of the umbilical cord, leading to a temporary decrease in oxygen supply to the fetus. It is important for the nurse to inform this group that they are at the highest risk for compression of the umbilical cord as this can result in fetal distress and potentially lead to serious complications if not promptly addressed.
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The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
A newborn is born to a mother with gestational diabetes. What complication is the nurse most likely to monitor for?
- A. Hypoglycemia
- B. Hyperthermia
- C. Jaundice
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Babies of diabetic mothers risk hypoglycemia due to high insulin.
A nurse is caring for a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?
- A. Administer prescribed analgesic medication.
- B. Encourage the client to rest between contractions.
- C. Massage the client's back.
- D. Turn the client onto her left side.
Correct Answer: C
Rationale: The gate control theory of pain proposes that non-painful input can close the "gates" to painful input, which helps to control and reduce pain perception. Massage, such as massaging the client's back, is a non-pharmacological intervention that can help close the gates and reduce the perception of pain. By massaging the client's back, the nurse is applying this theory to help manage the client's labor pain. Administering analgesic medication (Choice A) is a pharmacological intervention and not specifically related to the gate control theory. Choices B and D are also beneficial nursing actions but do not directly relate to the gate control theory of pain.
What emergency contraception has the best efficacy for prevention of pregnancy?
- A. Plan B
- B. Yuzpe
- C. copper IUC
- D. progesterone-only EC
Correct Answer: C
Rationale: Copper intrauterine devices (IUDs) have the best efficacy for prevention of pregnancy among emergency contraception options. Copper IUDs are over 99% effective when used as emergency contraception, making them more reliable than other methods like Plan B, Yuzpe, or progesterone-only EC. This high efficacy is due to the mechanism of action of copper IUDs, which prevent fertilization and implantation of the fertilized egg. Additionally, once inserted, a copper IUD can continue to provide ongoing contraception for up to 10 years, making it a long-term contraceptive option as well.
A nurse is assessing a preterm newborn who is at 32 weeks of gestation. Which of the following finding should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of less than 90
- C. Creases over the entire sole
- D. Sparse lanugo
Correct Answer: B
Rationale: A preterm newborn at 32 weeks of gestation is usually characterized by hip flexion posturing and a popliteal angle of less than 90 degrees. The popliteal angle is the angle at the back of the knee joint when the leg is flexed, and a value of less than 90 degrees is commonly seen in preterm newborns due to their muscle tone immaturity. This finding is consistent with the developmental stage of a preterm infant at 32 weeks gestation.