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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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A nurse is caring for a client who is in the transition phase of labor and reports a pain level of 7 on a scale of 0 to Which of the following actions should the nurse take?
- A. Instruct the client to use effleurage
- B. Apply counter pressure to the client sacral.
- C. Assist the client with patterned-paced breathing.
- D. Teach the client the technique of biofeedback.
Correct Answer: B
Rationale: In the transition phase of labor, the contractions are intense and the client may experience significant discomfort and pain. Applying counter pressure to the client's sacral area can help alleviate this pain by providing some relief and support. Counter pressure involves applying firm pressure with the palms or fists to the lower back or sacral area during contractions. This technique can help to relieve some of the pressure and discomfort experienced during contractions, making it a beneficial action for the nurse to take in this situation.
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.
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:
A nurse is caring for a client who has hyperemesis gravidarum. Which of the following laboratory tests should the nurse anticipate?
- A. Urine Ketones
- B. Rapid plasma regain
- C. Prothrombin time
- D. Urine culture
Correct Answer: A
Rationale: Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. One important laboratory test that the nurse should anticipate for a client with hyperemesis gravidarum is the urine ketones test. Ketones in the urine can indicate that the body is breaking down fat for energy instead of using glucose, which can occur during prolonged fasting or in conditions like hyperemesis gravidarum where there is severe vomiting leading to inadequate intake of nutrients. Monitoring urine ketones levels helps healthcare providers assess the severity of dehydration and metabolic derangement in these patients. It guides the management of fluid and electrolyte replacement to prevent complications like ketosis and metabolic acidosis.
A patient who is older than 35 years may have difficulty achieving pregnancy because
- A. prepregnancy medical attention is lacking.
- B. personal risk behaviors influence fertility.
- C. contraceptives have been used for an extended period of time.
- D. the ovaries may be affected by the normal aging process.
Correct Answer: D
Rationale: As women age, their ovarian reserve decreases and the quality of their eggs declines, making it more difficult to conceive. This is due to the normal aging process of the ovaries, which can lead to decreased fertility and an increased risk of chromosomal abnormalities in the embryos. Therefore, a patient who is older than 35 years may have difficulty achieving pregnancy because the ovaries may be affected by the normal aging process.