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Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is Indicated or contraindicated for the newborn
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer: B
Rationale: [0, 1, 0, 0]
Assess for grasp reflex in the affected extremity is the correct answer. This action is indicated as it allows the nurse to evaluate neurological function and muscle strength in the affected arm without causing harm. Educating parents to begin range of motion exercises after 1 week (A) is contraindicated as it may exacerbate injury or delay healing. Immobilizing the arm across the abdomen (C) is also contraindicated as it can restrict movement and hinder recovery. Instructing parents to limit physical handling for 2 weeks (D) is not the best option as it may not provide the necessary assessment and treatment for the newborn's condition.
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Which of the following conditions is the client most likely developing?
- A. Pelvic inflammatory.
- B. Ectopic pregnancy.
- C. Pyclonephritis.
- D. C-reactive protein.
- E. Beta hCG.
- F. Urinalysis.
Correct Answer: A
Rationale: [1, 0, 0, 0, 0, 0]
The correct answer is A: Pelvic inflammatory. Pelvic inflammatory disease is an infection of the female reproductive organs, often caused by sexually transmitted infections. It presents with symptoms like pelvic pain, abnormal vaginal discharge, and fever. Ectopic pregnancy (B) is the implantation of a fertilized egg outside the uterus and presents with abdominal pain and vaginal bleeding. Pyelonephritis (C) is a kidney infection, typically causing fever and flank pain. C-reactive protein (D) is a marker for inflammation and infection, not a specific condition. Beta hCG (E) is a hormone produced in pregnancy. Urinalysis (F) is a test to analyze urine composition, not a condition.
A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?
- A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL (less than 95 mg/dL).
- B. A client who is at 34 weeks of gestation and reports epigastric pain.
- C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL (11 to 16 g/dL).
- D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria.
Correct Answer: B
Rationale: The correct answer is B. The client at 34 weeks with epigastric pain is the priority as it could indicate preeclampsia, a serious condition requiring immediate attention to prevent harm to both the mother and the baby. Epigastric pain can be a sign of liver involvement in preeclampsia. Gestational diabetes (choice A) with slightly elevated blood glucose levels can be managed and monitored. Low hemoglobin levels at 28 weeks (choice C) may require treatment but are not as urgent as potential preeclampsia. Urinary symptoms at 39 weeks (choice D) could be indicative of a urinary tract infection, which is important but not as urgent as suspected preeclampsia.
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention as the client is Rh-negative and has just undergone an invasive procedure like amniocentesis, which carries a risk of fetal-maternal blood transfer. Administering Rh(0) Immune globulin helps prevent the development of Rh incompatibility, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) and monitoring the FHR (D) are important but not the priority immediately post-procedure. Observing for uterine contractions (B) is important but not the priority for an Rh-negative client after amniocentesis.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. After giving birth vaginally, the uterus should be midline and firm. Palpating it above the umbilicus and to the right indicates a full bladder displacing the uterus. Emptying the bladder will allow the uterus to return to its normal position. A: Reassessing in 2 hours is unnecessary as the issue is a full bladder. B: Administering simethicone is for gas relief and not relevant in this situation. D: Instructing the client to lie on their right side does not address the underlying issue of the full bladder.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring, the nurse should perform Leopold maneuvers to assess the fetal position, presentation, lie, and engagement. This helps in determining the optimal placement of the transducer for accurate monitoring of the fetal heart rate. It allows the nurse to locate the fetal back and position the transducer over the fetal heart for the best signal quality.
Choices A, C, and D are incorrect:
A: Determining progression of dilatation and effacement is not necessary before applying the external transducer.
C: Completing a sterile speculum exam is not needed for fetal monitoring.
D: Preparing a Nitrazine paper test is unrelated to applying an external transducer.