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Which explanation by the nurse correctly describes the occurrence of identical twins?
- A. Two separate ova are fertilized by identical sperm.
- B. The mother releases two identical ova.
- C. One fertilized ovum divides into two identical halves.
- D. Two identical ova are fertilized by two identical sperm.
Correct Answer: C
Rationale: Identical twins result from one fertilized ovum splitting into two identical embryos, sharing the same genetic material.
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The experienced nurse is observing the new nurse determine the fetal position of the pregnant client using Leopold maneuver. The experienced nurse determines that the new nurse correctly identifies the first Leopold maneuver when placing the hands in which position illustrated first?
- A. Image A
- B. Image B
- C. Image C
- D. Image D
Correct Answer: B
Rationale: This illustration shows the first step of Leopold’s maneuver. The nurse palpates the fundus to determine which fetal body part (e.g., head or buttocks) occupies the uterine fundus. Image A shows the fourth Leopold maneuver. The nurse’s fingertips are used to determine the location of the cephalic prominence. Image C shows the third Leopold maneuver (“Pawlik maneuver”). During this maneuver the fetal part in the fundal region is compared with the part in the lower uterine segment. It is completed primarily to confirm that the fetus is in a cephalic (head) presentation. Image D shows the second Leopold maneuver. The second maneuver determines the location of the fetal back or spine.
The home care nurse is visiting the mother and her 6-day-old son. The nurse observes that the infant is sleeping in a crib on his back and has a blanket draped over his body. The mother had been sleeping in a nearby room. Which statements are appropriate for the nurse to make in response to this situation? Select all that apply.
- A. “I’m glad to see that you are sleeping while your baby sleeps.”
- B. “Having your baby sleep on his back reduces the risk of SIDS.”
- C. “It is best for you to sleep in the same room as your newborn.”
- D. “Position your baby on his tummy and side when he is awake.”
- E. “When using a blanket, always tuck its sides under the mattress.”
Correct Answer: A,B,D
Rationale: This is an appropriate statement. Sleeping while the infant sleeps will help the mother get the rest she needs. This is an appropriate statement. The American Academy of Pediatricians recommends the supine position for infant sleeping to decrease the risk of SIDS. The mother should be in close proximity and ready to respond when the infant wakes and/or cries, but she does not need to sleep in the same room as the infant. This is an appropriate statement. While awake the infant should be positioned prone and side-lying to help build neck muscles and decrease the chance of deformation plagiocephaly. Deformation plagiocephaly is a malformation of the skull caused by consistently lying on the back. A blanket, if used, should swaddle the infant rather than being draped over the infant. Swaddling helps prevent suffocation. Tucking the blanket sides under the mattress does not prevent suffocation.
The client tells the nurse, “Most days, I am so happy I am pregnant, but other days, I am not sure that I am ready to have a baby.” Which is the most accurate response from the nurse?
- A. “This is such a happy time in your life. You need to be optimistic to feel happy.”
- B. “How does your spouse feel about the pregnancy? I hope he is happy about the baby.”
- C. “Feeling differently from day to day is normal. How do you feel today?”
- D. “Why do you feel this way? Is there something I can do to make it better for you?”
Correct Answer: C
Rationale: It is most therapeutic to acknowledge the client’s feelings and probe for more information on her thoughts and feelings about the pregnancy. Not all clients consider pregnancy a happy time in their lives, and the nurse should never tell the client how to feel. The nurse should not divert the client’s concerns away from self by bringing up the father’s adaptation to the pregnancy, even though paternal adaptation is related to maternal adaptation. The client may not be able to identify why she has the feelings she is experiencing or how the nurse can make her feel better. This response does not provide an avenue for further exploration of the client’s concerns.
Which explanation by the nurse accurately identifies the recommended weight gain for a pregnant client who has a normal prepregnancy weight?
- A. Less than 15 pounds (<6.8 kg)
- B. 15 to 20 pounds (6.8 to 9 kg)
- C. 25 to 35 pounds (11.3 to 15.9 kg)
- D. No more than 40 pounds (≤18.1 kg)
Correct Answer: C
Rationale: For a woman with normal prepregnancy weight, the recommended weight gain is 25-35 pounds to support fetal development.
Which nursing instruction given to the client complaining about shortness of breath is most appropriate?
- A. Contact your health care provider immediately.
- B. Decrease your activity level to conserve oxygen.
- C. Ask your physician for a mild sedative.
- D. Sleep with your upper body elevated on pillows.
Correct Answer: D
Rationale: Sleeping with the upper body elevated reduces pressure on the diaphragm, easing shortness of breath.