Nokea
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 client at 28 weeks' gestation reports regular uterine contractions. What is the nurse's priority intervention?
- A. Administer tocolytic medication.
- B. Perform a sterile vaginal examination.
- C. Assess fetal heart rate and contraction pattern.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing fetal heart rate and contraction patterns is critical to evaluate the risk of preterm labor.
Which order should the nurse implement first?
- A. Give 1L LR IV (VS indicate hypovolemia from dehydration,
- B. LR will reestablish vascular volume and bring BP up)
- C. Weigh the client
- D. Administer Maalox orally
Correct Answer: A
Rationale: The correct order of implementation in this scenario should focus on addressing the immediate physiological needs of the patient. The vital signs indicating hypovolemia from dehydration require prompt action to stabilize the patient's condition. Giving 1L of LR IV will help reestablish vascular volume, improve blood pressure, and address the underlying issue of dehydration. By addressing the hypovolemia first, the nurse can effectively start the process of stabilizing the patient before moving on to other interventions such as weighing the client, administering Maalox orally, or encouraging liquid intake.
A pregnant woman tells the nurse-midwife, 'I've heard that if I eat certain foods during my pregnancy, the baby will be a boy.' The nurse-midwife should explain that this is a myth, and that the sex of the baby is determined at what time?
- A. At the time of ejaculation
- B. At the time of fertilization
- C. At the time of implantation
- D. At the time of differentiation
Correct Answer: B
Rationale: The sex of a baby is determined at fertilization. Sperm cells carry either an X or Y chromosome, while the ovum only carries an X chromosome. If the sperm contributes an X chromosome, the baby will be female, and if it contributes a Y chromosome, the baby will be male.
Pregnant Black people have more complications resulting from epigenetic changes caused by prolonged stress due to racism and discrimination. What complication could arise because of this history?
- A. postterm pregnancy
- B. preeclampsia
- C. liver disease
- D. cholestasis of pregnancy
Correct Answer: B
Rationale: Prolonged stress and systemic racism contribute to higher rates of preeclampsia in Black pregnant individuals.
The nurse is preparing a client for an amniocentesis. What is the priority nursing action?
- A. Verify signed informed consent.
- B. Administer prescribed analgesics.
- C. Encourage the client to empty their bladder.
- D. Position the client in a semi-Fowler's position.
Correct Answer: A
Rationale: Ensuring informed consent is signed is a critical step before an invasive procedure like amniocentesis.