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Which newborn is at highest risk of a skin infection? of the FHR?
- A. Infant born at 36 weeks who is being bottle fed
- B. Right lower abdomen
- C. Infant whose umbilical cord fell off on day 8 of life
- D. Near client umbilicus
Correct Answer: C
Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.
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What blood test is important for potential blood type incompatibility issues during pregnancy?
- A. complete blood count (CBC)
- B. blood glucose
- C. blood type and Rh factor
- D. blood lipid profile
Correct Answer: C
Rationale:
The nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result folic acid deficiency?
- A. iron deficiency anemia
- B. Poor bone formation
- C. Macrosomia fetus
- D. Neural tube defect
Correct Answer: D
Rationale: Folic acid is essential for the development of the neural tube in the fetus. When a pregnant woman has a deficiency in folic acid, it can lead to neural tube defects in the fetus. Neural tube defects are serious birth defects that affect the brain, spine, or spinal cord of the baby. The most common types of neural tube defects include spina bifida and anencephaly. Therefore, it is crucial for women of childbearing age to ensure an adequate intake of folic acid to prevent such birth defects.
A patient's newborn is neurologically impaired. The most important nursing action should be:
- A. Assist the patient and her family with the grieving process.
- B. Perform neurological assessments of the newborn every four hours.
- C. Arrange for social services to discuss possible placement of the newborn
- D. Obtain an order for an antidepressant to help the patient cope with the depressing news.
Correct Answer: A
Rationale: The most important nursing action when a patient's newborn is neurologically impaired is to assist the patient and her family with the grieving process. This situation can be extremely emotionally challenging for the parents and family as they come to terms with the newborn's condition. Providing support, empathy, and resources for coping with the grief is essential in helping the family navigate this difficult time. By being present, listening, and offering comfort, the nurse can help the family process their emotions and begin to cope with the situation. This support is crucial in promoting the overall well-being of the family as they adjust to the new reality of caring for a neurologically impaired newborn.
What is the primary nursing concern for a mother receiving magnesium sulfate therapy?
- A. Monitor blood pressure every 4 hours
- B. Monitor deep tendon reflexes hourly
- C. Assess respiratory rate and effort
- D. Prepare for delivery if signs of toxicity appear
Correct Answer: B
Rationale: Monitoring reflexes detects early signs of magnesium toxicity.
A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?
- A. Vomiting
- B. Tachycardia
- C. Respiratory depression
- D. Hypotension
Correct Answer: D
Rationale: Epidural anesthesia can cause hypotension as a common complication. This occurs because the local anesthetic affects the sympathetic nerves, leading to vasodilation and subsequent lowering of blood pressure. It is crucial for nurses to monitor the client's blood pressure closely and be prepared to administer IV fluids or medications to address the hypotension promptly. Vomiting, tachycardia, and respiratory depression are not typically associated with epidural anesthesia; therefore, hypotension is the most likely complication to be identified in this scenario.