Nokea
Which of the following is a professional standard for nursing practice in maternal and newborn healthcare?
- A. Interprofessional collaboration
- B. Evidence-based practice
- C. Quality improvement
- D. All of the above
Correct Answer: D
Rationale: Professional standards include interprofessional collaboration, evidence-based practice, and quality improvement.
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A nurse is preparing to assess fetal heart tones for a client who is at 12 weeks of gestation. Which of the following actions should the nurse take?
- A. Place the client in a side-lying position prior to assessing the fetal heart rate
- B. Measure the fundal height to determine the placement of the ultrasound stethoscope.
- C. Position the ultrasound stethoscope above the symphysis pubis to assess the fetal heart rate.
- D. Perform Leopold maneuvers prior to auscultating the fetal heart rate.
Correct Answer: C
Rationale: At 12 weeks of gestation, the fetal heart rate is best assessed using an ultrasound stethoscope positioned above the symphysis pubis. Leopold maneuvers are not necessary at this early stage.
A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: Decreasing lighting levels helps reduce overstimulation, which can exacerbate symptoms of neonatal abstinence syndrome.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: The correct answer is A: Assist the client to ambulate to the bathroom. This action helps in promoting normal voiding patterns post-cesarean birth. Ambulation can aid in relieving pressure on the bladder, stimulating the urge to urinate, and facilitating the flow of urine. It also promotes circulation, which can help in reducing the risk of urinary retention.
Choice B: Inserting an indwelling urinary catheter should not be the initial intervention as it carries a risk of introducing infection and may not be necessary at this point.
Choice C: Performing a bladder scan can be considered if the client is unable to void after ambulation and other interventions have been attempted.
Choice D: Administering a diuretic is not appropriate in this situation as the client is experiencing difficulty in urinating rather than retaining excessive urine.
In summary, assisting the client to ambulate to the bathroom is the most appropriate initial action to address the client's complaint and promote normal voiding.
Select the 5 findings that require follow-up by the nurse.
- A. Lower extremity assessment
- B. Fetal heart tracing
- C. Weight assessment
- D. Blood pressure
- E. Nausea
- F. Respiratory assessment
- G. DTR
Correct Answer: A,C,D,E,G
Rationale: Administer oxygen
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate energy supply to respiratory muscles. Hypertonia (choice A) is not a typical manifestation of hypoglycemia. Increased feeding (choice B) is a compensatory mechanism to raise blood glucose levels. Hyperthermia (choice C) is not directly related to hypoglycemia. Therefore, the most appropriate choice indicating hypoglycemia in this scenario is respiratory distress.