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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. BP of 132/84 mm Hg.
- B. Double vision.
- C. Weight gain of 1 kg (2.2 lb).
- D. Pedal edema.
Correct Answer: B
Rationale: Double vision can indicate preeclampsia or neurological issues, requiring immediate reporting for further evaluation and management.
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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.
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 newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 hours.
- B. Give the newborn 30 ml of distilled water after each feeding.
- C. Monitor the newborn's blood glucose level every hour.
- D. Apply a water-based ointment to the newborn's skin every 6 hours.
Correct Answer: A
Rationale: Repositioning the newborn every 2 hours ensures even exposure to phototherapy light, preventing skin breakdown and effectively reducing bilirubin levels.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will make sure that just the nipple is in my baby’s mouth.
- B. I will apply vitamin E oil to my nipples after each feeding.
- C. I will nurse my baby for 5 to 10 minutes on each breast.
- D. I will lay my baby on a pillow at the level of my breast.
Correct Answer: D
Rationale: Laying the baby on a pillow at breast level ensures proper positioning and latch, key to successful breastfeeding.
A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.
Which of the following discomforts should the nurse include in the teaching?
- A. Tingling in the fingers.
- B. Round ligament pain.
- C. Urinary urgency and frequency.
- D. Perineal itching and pressure.
Correct Answer: C
Rationale: Urinary urgency and frequency are common in the first trimester due to hormonal changes and increased pelvic blood flow, pressing on the bladder.