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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. Place the newborn supine and apply pressure to the soles of the feet.
- B. Pull the newborn up by the wrist from a supine position.
- C. Touch the corner of the newborn's mouth.
- D. Stroke upward on the lateral aspect of the sole of the newborn's foot.
Correct Answer: D
Rationale: Stroking upward on the lateral sole elicits the Babinski reflex, causing toes to fan out, a normal newborn response.
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Nurses' Notes Two weeks ago (32 weeks gestation): The client presented for a routine visit and denied vaginal bleeding or fluid leakage. Reports mild insomnia and occasional mild uterine cramping. 1+ nonpitting edema noted in bilateral feet and ankles. Weight recorded as 84 kg (185 lb). Today (0930): The client reports mild epigastric pain for the past three days and occasionally 'seeing spots' in her vision. 2+ nonpitting edema noted bilaterally in feet and ankles, and mild facial edema present. The client states her fingers 'swelled up overnight,' preventing her from wearing rings. Weight has increased to 86 kg (190 lb). Vital Signs: Blood pressure: 160/100 mm Hg, Heart rate: 88/min, Respiratory rate: 18/min, Temperature: 36.9°C (98.4°F), Oxygen saturation: 98% on room air. Diagnostic Results: Hemoglobin: 10 g/dL, Hematocrit: 35.9%, Platelet count: 95,000/mm³, AST: 200 U/L, ALT: 25 U/L, Total bilirubin: 1.8 mg/dL, Urine protein: 2+.
Which of the following findings should the nurse report to the primary health care provider?
- A. Platelet count
- B. Hematocrit value
- C. Nonstress test result
- D. Weight gain
- E. Edema
- F. Blood pressure
- G. BUN
Correct Answer: A,D,E,F
Rationale: Low platelets, rapid weight gain, edema, high BP, and proteinuria indicate preeclampsia, requiring immediate reporting.
The nurse is collecting data from the client 24 hr later.
How should the nurse interpret the findings?
- A. Moderate lochia rubra: Sign of potential improvement.
- B. Client reports decreased level of pain: Sign of potential improvement.
- C. Temperature 38.4°C (101°F): Sign of potential worsening condition.
- D. WBC count 15,000/mm³ : Sign of potential worsening condition.
Correct Answer: C
Rationale: A temperature of 38.4°C (101°F) suggests a potential infection or inflammatory process, indicating a worsening condition.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Encourage the client to continue to breastfeed.
- B. Prepare the client for an abdominal sonogram.
- C. Encourage the client to wear a loose-fitting bra.
- D. Limit the client's daily fluid intake.
Correct Answer: A
Rationale: Encouraging the client to continue to breastfeed helps empty the breast, reducing pain and inflammation and promoting healing from mastitis.
A nurse is reinforcing discharge instructions about breastfeeding with a client.
Which of the following statements should the nurse make?
- A. You should recognize that your baby sucking on his hands is a hunger cue.
- B. You should feed your baby six times a day.
- C. You should feed your baby for 10 minutes on each breast.
- D. You should wake your baby at least every 6 hours at night for feedings.
Correct Answer: A
Rationale: Recognizing hand-sucking as a hunger cue ensures timely breastfeeding, supporting nutritional needs and feeding success.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Maternal temperature 38.3°C (101°F).
- B. Fetal heart tones 98/min.
- C. Foul-smelling vaginal discharge.
- D. Amniotic fluid with meconium noted.
Correct Answer: B
Rationale: Fetal heart tones at 98/min are significantly lower than the normal range (110-160/min), indicating fetal distress and requiring immediate intervention.