Nokea
Which of the following is a potential complication of a placental abruption?
- A. Preterm labor
- B. Fetal distress
- C. Polyhydramnios
- D. All of the above
Correct Answer: B
Rationale: The correct answer is B: Fetal distress. Placental abruption is the premature separation of the placenta from the uterus, leading to decreased oxygen and nutrients to the fetus, causing fetal distress. Preterm labor (choice A) can occur due to placental abruption, but it is not a direct complication. Polyhydramnios (choice C) is excessive amniotic fluid, which is not typically associated with placental abruption. Choice D is incorrect as preterm labor and polyhydramnios are not direct complications. Fetal distress is the most immediate and concerning complication of placental abruption due to the compromised blood flow to the fetus.
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A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: Chin quivering is a sign of pain in newborns and should be addressed with appropriate pain management interventions.
A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. In newborns of mothers with gestational diabetes mellitus, hypoglycemia can occur due to the abrupt cessation of the maternal glucose supply. Jitteriness is a common manifestation of hypoglycemia in newborns. This is because the brain is highly dependent on glucose for energy, and low blood sugar levels can affect neurological function, leading to symptoms like jitteriness. Abdominal distention, petechiae, and increased muscle tone are not typical manifestations of hypoglycemia in newborns with a history of maternal gestational diabetes mellitus.
A nurse is assessing a newborn following a forceps-assisted birth. Which of the following clinical manifestations should the nurse identify as a complication of this birth method?
- A. Polycythemia
- B. Hypoglycemia
- C. Bronchopulmonary dysplasia
- D. Facial palsy
Correct Answer: D
Rationale: The correct answer is D: Facial palsy. Forceps-assisted birth can lead to facial nerve injury, resulting in facial palsy. This occurs due to pressure exerted by the forceps on the baby's face during delivery. The other choices are incorrect because: A) Polycythemia is not directly related to forceps-assisted birth. B) Hypoglycemia is more commonly associated with maternal diabetes or prematurity. C) Bronchopulmonary dysplasia is a lung condition seen in premature infants requiring prolonged mechanical ventilation. In summary, facial palsy is the most likely complication of forceps-assisted birth due to potential nerve injury, while the other choices are less directly linked to this birthing method.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Pressing the handheld button when the client feels fetal movement helps to correlate fetal movements with changes in the fetal heart rate, which is the purpose of the nonstress test.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.