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A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Touch the corner of the newborn's mouth.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Stroke upward on the lateral aspect of the sole of the newborn's foot
- D. Pull the newborn up by the wrist from a supine position.
Correct Answer: C
Rationale: Stroking upward on the lateral sole elicits the Babinski reflex, where toes fan and extend, a normal newborn response indicating neurological health.
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A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. White blood cell count is an indicator of anemia.
- B. Urine specific gravity identifies my risk for pregnancy induced hypertension
- C. Platelet count identifies if I am at risk for bleeding
- D. Sedimentation rate checks for signs of cancer
Correct Answer: C
Rationale: Platelet count identifies bleeding risk by assessing clotting ability, a key concern in pregnancy, showing the client understands the test's purpose accurately.
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?
- A. You should check the identity of individuals who come to remove your baby from the room
- B. We will scan your baby's identification bracelet each time check on him
- C. We will match the bracelet on your baby with his footprint record each shift
- D. Your baby will wear an electronic bracelet when he is out of your room
Correct Answer: A
Rationale: It's crucial for parents to verify the identity of anyone who comes to take their baby out of the room. This helps ensure the baby's safety and prevents unauthorized individuals from taking the baby. Hospital staff usually wear identification badges, and parents should be encouraged to ask for and verify this identification.
A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to start chemotherapy immediately.
- B. I will need to attend a support group when I get home.
- C. I will need an amniocentesis within 1 month.
- D. I will need home palliative services after I am discharged from the hospital.
Correct Answer: B
Rationale: Attending a support group provides emotional support and coping strategies post-molar pregnancy, reflecting an understanding of the psychosocial resources available.
A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Pedal edema
- B. BP of 132/84 mm Hg
- C. Weight gain of 1 kg (2.2 lb)
- D. Double vision
Correct Answer: D
Rationale: Double vision can indicate preeclampsia or other serious conditions in pregnancy, requiring prompt reporting for further evaluation and management.
A nurse is reinforcing teaching with a client who is at 24 weeks of gestation and has opioid use disorder.
Which of the following statements should the nurse make?
- A. You will be prescribed methadone.
- B. You will be prescribed aripiprazole.
- C. You will be prescribed naloxone.
- D. You will be prescribed diazepam.
Correct Answer: A
Rationale: Methadone maintenance therapy is a commonly used treatment for opioid use disorder in pregnant women. Methadone helps to manage withdrawal symptoms, reduce cravings, and stabilize the individual, promoting healthier outcomes for both the mother and the baby.