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When assessing newborn reflexes, what action should be taken to elicit the Moro reflex?
- A. Perform a sharp hand clap near the infant.
- B. Hold the newborn vertically allowing one foot to touch the table surface.
- C. Place a finger at the base of the newborn's toes.
- D. Turn the newborn's head quickly to one side.
Correct Answer: A
Rationale: The correct answer is A: Perform a sharp hand clap near the infant. This action elicits the Moro reflex by stimulating the startle response. The Moro reflex involves the baby's arms spreading out and then coming back in when they feel like they are falling. This reflex helps in assessing the baby's neurological development. Choices B, C, and D do not specifically target the Moro reflex and may elicit other reflexes or responses. Holding the newborn vertically (B) may trigger the stepping reflex, placing a finger at the base of the toes (C) may provoke the Babinski reflex, and turning the newborn's head (D) may elicit the tonic neck reflex.
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A client in the antepartum unit is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?
- A. Placenta previa
- B. Prolapsed cord
- C. Incompetent cervix
- D. Abruptio placentae
Correct Answer: D
Rationale: The correct answer is D, abruptio placentae. This condition is characterized by sudden onset of continuous abdominal pain and vaginal bleeding, common at 36 weeks gestation with pregnancy-induced hypertension. It occurs when the placenta prematurely separates from the uterine wall. Placenta previa (A) presents painless bleeding, prolapsed cord (B) involves cord presenting before the fetus, and incompetent cervix (C) leads to painless dilation of the cervix. Thus, abruptio placentae is the most likely complication in this scenario.
A healthcare provider is assessing a newborn who has a coarctation of the aorta. Which of the following should the provider recognize as a clinical manifestation of coarctation of the aorta?
- A. Increased blood pressure in the arms with decreased blood pressure in the legs
- B. Decreased blood pressure in the arms with increased blood pressure in the legs
- C. Increased blood pressure in both the arms and the legs
- D. Decreased blood pressure in both the arms and the legs
Correct Answer: A
Rationale: The correct answer is A: Increased blood pressure in the arms with decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to increased blood pressure in the arms due to the pressure build-up before the narrowing and decreased blood pressure in the legs due to reduced blood flow beyond the narrowing. This pressure difference is a classic clinical manifestation of coarctation of the aorta.
Choices B, C, and D are incorrect because they do not align with the pathophysiology of coarctation of the aorta. B is incorrect as decreased blood pressure in the arms is not typical. C is incorrect as increased blood pressure in both the arms and legs does not reflect the characteristic pressure difference caused by the aortic narrowing. D is incorrect as decreased blood pressure in both the arms and legs is not consistent with the presentation of coarctation of the aorta.
A pregnant client is learning about Kegel exercises in the third trimester. Which statement signifies understanding of the teaching?
- A. These exercises facilitate preventing constipation.
- B. These exercises aid pelvic muscle stretching during birth.
- C. They assist in decreasing backaches.
- D. They can prevent additional stretch marks.
Correct Answer: B
Rationale: The correct answer is B because Kegel exercises help strengthen the pelvic floor muscles, which can aid in pelvic muscle stretching during birth. This can potentially reduce the risk of pelvic floor dysfunction postpartum.
A is incorrect because Kegel exercises do not directly prevent constipation.
C is incorrect because while Kegel exercises may indirectly help with backaches by improving pelvic floor muscle support, they are not specifically targeted for backache relief.
D is incorrect as Kegel exercises do not prevent stretch marks, as stretch marks are related to skin elasticity rather than muscle tone.
During a Leopold maneuver, a healthcare professional determines that the fetus is in an RSA position. Which fetal presentation should be documented in the client's medical record?
- A. Vertex
- B. Shoulder
- C. Breech
- D. Mentum
Correct Answer: C
Rationale: During a Leopold maneuver, if the healthcare professional determines that the fetus is in an RSA position, it means the fetal back is on the right side, and the small parts are on the left side, indicating a breech presentation. Therefore, the correct answer is C: Breech. The other choices are incorrect because:
A: Vertex refers to the head-first position.
B: Shoulder presentation would involve feeling the shoulder first during the maneuver.
D: Mentum presentation would involve feeling the chin first, which is not the case in an RSA position.
A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?
- A. Fetal attitude is in general flexion.
- B. Fetal lie is longitudinal.
- C. Maternal pelvis is gynecoid.
- D. Fetal position is persistent occiput posterior.
Correct Answer: D
Rationale: The correct answer is D: Fetal position is persistent occiput posterior. This position, where the baby's head is facing the mother's abdomen instead of her back, can lead to severe backache and difficulty during labor due to increased pressure on the mother's spine. This malposition can impede the progress of labor and cause prolonged labor.
Explanation of incorrect choices:
A: Fetal attitude in general flexion is a normal position and not typically associated with severe backache.
B: Fetal lie being longitudinal refers to the baby's position in relation to the mother's spine and is not directly related to backache.
C: Maternal pelvis being gynecoid is a favorable shape for childbirth and is unlikely to cause severe backache during labor.