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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 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.
A client gave birth 2 hours ago, and their blood pressure is 60/50 mm Hg. What action should the nurse take first?
- A. Evaluate the firmness of the uterus.
- B. Initiate oxygen therapy via a non-rebreather mask.
- C. Administer oxytocin infusion.
- D. Obtain a type and crossmatch.
Correct Answer: A
Rationale: The correct action for the nurse to take first is to evaluate the firmness of the uterus. This is because the client's low blood pressure may indicate postpartum hemorrhage, which is a common complication after childbirth. Assessing the firmness of the uterus helps determine if there is uterine atony, a leading cause of postpartum hemorrhage. By addressing uterine atony promptly, the nurse can prevent further blood loss and stabilize the client's condition.
Summary:
- Option B, initiating oxygen therapy, is not the first priority as the client's low blood pressure is likely due to hemorrhage rather than hypoxemia.
- Option C, administering oxytocin infusion, may be necessary to address uterine atony but should only be done after assessing the firmness of the uterus.
- Option D, obtaining a type and crossmatch, is important for potential blood transfusion but is not the immediate priority compared to assessing for uterine atony.
During newborn gestational age assessment, which finding should be recorded as part of this assessment on the newborn?
- A. Acrocyanosis of hands and feet
- B. Anterior fontanel soft and level
- C. Plantar creases cover 2/3 of sole
- D. Vernix caseosa in inguinal creases
Correct Answer: C
Rationale: Rationale for Choice C (Correct Answer):
Plantar creases covering 2/3 of the sole is a standard newborn assessment finding indicating normal development. This is a key milestone in assessing the newborn's muscle tone and neurological status. Absence or presence of plantar creases can provide insights into potential developmental issues. Therefore, recording this finding is crucial for monitoring the newborn's growth and development.
Summary of Other Choices:
A: Acrocyanosis of hands and feet - Common benign finding in newborns due to immature circulation, not a specific part of newborn assessment.
B: Anterior fontanel soft and level - Important assessment, but not specific to gestational age assessment.
D: Vernix caseosa in inguinal creases - Normal finding, but not a specific part of gestational age assessment.
A nurse is admitting a term newborn following a cesarean birth. The nurse observes that the newborn's skin is slightly yellow. This finding indicates the newborn is experiencing a complication related to which of the following?
- A. Maternal/newborn blood group incompatibility
- B. Absence of vitamin K
- C. Physiologic jaundice
- D. Maternal cocaine abuse
Correct Answer: A
Rationale: Step-by-step rationale for why the correct answer is A:
1. Maternal/newborn blood group incompatibility can result in hemolytic disease of the newborn.
2. Hemolytic disease causes an increase in bilirubin levels, leading to jaundice.
3. Jaundice in this case is due to the breakdown of red blood cells and elevated unconjugated bilirubin levels.
4. Physiologic jaundice is a normal process in newborns and usually appears after the first 24 hours of life.
5. Absence of vitamin K would not directly cause jaundice.
6. Maternal cocaine abuse is not typically associated with neonatal jaundice.
In summary, the correct answer is A because maternal/newborn blood group incompatibility can lead to hemolytic disease and subsequent jaundice, while the other choices are not directly related to neonatal jaundice.
A client at 39 weeks of gestation in a prenatal clinic asks about signs preceding labor. Which of the following should the nurse identify as a sign that precedes labor?
- A. Decreased vaginal discharge
- B. A surge of energy
- C. Urinary retention
- D. Weight gain of 0.5 to 1.5 kg
Correct Answer: B
Rationale: The correct answer is B: A surge of energy. This is a sign that precedes labor as the body may experience a burst of energy known as the "nesting instinct." This surge can occur as the body prepares for the upcoming physical demands of labor.
A: Decreased vaginal discharge is not a sign of impending labor; in fact, there may be an increase in vaginal discharge as the body prepares for childbirth.
C: Urinary retention is not a sign of impending labor and can be a symptom of other issues such as a urinary tract infection.
D: Weight gain of 0.5 to 1.5 kg is not a specific sign of labor approaching; weight fluctuations during pregnancy are common and can vary based on various factors.