Nokea
Which nursing action is most appropriate for a newborn experiencing apnea?
- A. Place the newborn in a prone position
- B. Administer oxygen and stimulate the newborn
- C. Place the newborn under a radiant warmer
- D. Initiate chest compressions immediately
Correct Answer: B
Rationale: Administering oxygen and stimulating the newborn resolves apnea episodes.
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A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 min, last 90 sec, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction and a return to baseline after the contraction is over. Which of the following actions should the nurse take?
- A. Decrease the rate of infusion of the maintenance IV solution.
- B. Discontinue the infusion of the IV oxytocin.
- C. Increase the rate of infusion of the IV oxytocin.
- D. Slow the client's rate of breathing.
Correct Answer: B
Rationale: The described scenario suggests the presence of late decelerations, which occur when uteroplacental insufficiency leads to decreased fetal oxygenation. In this case, the late decelerations are evident with each contraction, indicating a potential adverse reaction to the oxytocin infusion. The appropriate action would be to discontinue the infusion of IV oxytocin to prevent further compromise to fetal well-being. Alternatively, the nurse should consider repositioning the mother, administering oxygen via a face mask, and notifying the healthcare provider for further assessment and interventions.
A community health nurse is providing education on gestational diabetes mellitus (GDM) to a group of clients who are pregnant when discussing risk factors, which of the following ethnicities should the nurse identify as having the lowest incidence of GDM?
- A. Asian
- B. Non-Hispanic White American
- C. Hispanic
- D. African American
Correct Answer: B
Rationale: Non-Hispanic White Americans have been reported to have the lowest incidence of gestational diabetes mellitus (GDM) compared to other ethnicities. Studies have shown that Asian, Hispanic, and African American populations have higher rates of developing GDM during pregnancy. This may be due to genetic predispositions, lifestyle factors, and varying degrees of insulin resistance among different ethnic groups. Therefore, when discussing risk factors for GDM, the community health nurse should identify Non-Hispanic White Americans as having the lowest incidence of GDM.
The nurse is assessing a client at 20 weeks' gestation with suspected anemia. What lab finding supports this diagnosis?
- A. Hemoglobin of 10 g/dL.
- B. Platelet count of 150,000 mm3.
- C. Hematocrit of 40%.
- D. White blood cell count of 8,000 mm3.
Correct Answer: A
Rationale: A hemoglobin level of 10 g/dL is below normal during pregnancy and indicates anemia.
The nurse is caring for a client with preeclampsia. What is the most important assessment?
- A. Daily weight.
- B. Urine protein levels.
- C. Fetal heart rate.
- D. Blood pressure.
Correct Answer: D
Rationale: Blood pressure monitoring is critical to prevent complications such as eclampsia and placental issues in preeclampsia.
The patient's family history includes sickle cell disease. The patient's partner also has sickle cell disease in the family history. What type of test should the nurse discuss with the couple due to their family history?
- A. carrier screening for both parents
- B. ultrasound at 6 weeks’ gestation
- C. glucose screening for both parents
- D. thyroid testing
Correct Answer: A
Rationale: