Nokea
The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are:
- A. benign to the woman but cause death to the fetus.
- B. sexually transmitted.
- C. capable of infecting the fetus.
- D. transmitted to the pregnant woman by a vector.
Correct Answer: C
Rationale: The correct answer is C because TORCH infections (Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes) are grouped together due to their ability to infect the fetus during pregnancy. These infections can lead to severe complications in the developing fetus, including congenital disabilities and even fetal death. Choices A, B, and D do not accurately describe the main reason TORCH infections are grouped together. Choice A focuses on the outcomes for the woman and fetus, not the reason for grouping the infections. Choice B is incorrect as TORCH infections are not primarily sexually transmitted. Choice D is also incorrect as TORCH infections are not transmitted by vectors but through various routes such as transplacentally or through contact with infected bodily fluids.
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A new mother receives instructions about care of her newborn son's circumcision. Which statement made by the mother indicates that further teaching is needed?
- A. I will call the doctor if my baby's penis starts to bleed.
- B. I should wash off any yellowish mucous on my baby's penis.
- C. I will put vaseline on his penis every time I change his diaper.
- D. I should give my baby a sponge bath for the first week.
Correct Answer: B
Rationale: The correct answer is B. Washing off yellowish mucous is not recommended as it may be a normal part of the healing process after circumcision. The yellowish mucous is likely to be a scab or healing tissue, and washing it off could interfere with the healing process or cause infection. It is essential to let it fall off naturally. Choices A, C, and D are correct because calling the doctor for bleeding, applying vaseline for protection, and giving a sponge bath for hygiene are appropriate post-circumcision care.
The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the main goal of Leopold's maneuvers?
- A. To determine whether the client's cervix has dilated
- B. To assess the frequency and intensity of the contractions
- C. To assess whether membranes have been ruptured
- D. To determine the presentation and position of the fetus
Correct Answer: D
Rationale: The correct answer is D: To determine the presentation and position of the fetus. Leopold's maneuvers involve a series of palpations to assess the fetal lie, presentation, position, and engagement. By performing these maneuvers, the nurse can determine the position of the fetus in relation to the mother's pelvis and whether the baby is in a vertex or breech presentation. This information is crucial in planning for a safe delivery and identifying any potential complications.
Other choices are incorrect because:
A: Leopold's maneuvers do not directly assess cervical dilation.
B: Contractions are typically monitored separately using a tocodynamometer.
C: Checking for ruptured membranes is done through a separate assessment.
In summary, Leopold's maneuvers primarily focus on assessing the presentation and position of the fetus to guide the delivery process effectively.
The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate?
- A. Instruct the mother to breathe slowly because this is a sign of hyperventilation
- B. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions
- C. Turn the woman onto her left side to relieve pressure on the umbilical cord
- D. Reduce the oral and IV fluids to decrease circulatory overload
Correct Answer: C
Rationale: The correct answer is C: Turn the woman onto her left side to relieve pressure on the umbilical cord. Variable decelerations are associated with umbilical cord compression. Turning the woman onto her left side can help relieve pressure on the cord, improving fetal oxygenation. This position change is a non-invasive, quick intervention that can potentially resolve the variable decelerations.
Choice A is incorrect because variable decelerations are not typically associated with hyperventilation. Choice B is incorrect as decreasing Pitocin may not directly address the underlying cause of the variable decelerations. Choice D is incorrect because reducing fluids may not address the immediate concern of umbilical cord compression.
When planning for the care of an infant experiencing neonatal abstinence syndrome, which nursing assessment is most important?
- A. The mother's ability to provide a safe environment
- B. The extent of addiction of the mother
- C. The mother's ability to obtain treatment
- D. The severity of the infant's withdrawal
Correct Answer: A
Rationale: The correct answer is A: The mother's ability to provide a safe environment. This is crucial because infants with neonatal abstinence syndrome require a stable and safe environment for optimal care and recovery. Assessing the mother's ability to provide this environment helps ensure the infant's safety and well-being. Choice B is incorrect because the extent of the mother's addiction, while important, does not directly impact the immediate care of the infant. Choice C is incorrect as the focus should be on the current situation and care of the infant rather than the mother obtaining treatment. Choice D is incorrect as the severity of the infant's withdrawal, though important, is not the most critical assessment in planning care.
Which of the following emotional manifestations demonstrates an improvement in a 7-month-old infant diagnosed with nonorganic failure to thrive?
- A. Infant has no fear of strangers.
- B. Infant scans environment with wide-eyed gaze.
- C. Infant is passive and sleeps well.
- D. Infant likes to be held and touched.
Correct Answer: D
Rationale: The correct answer is D: Infant likes to be held and touched. This demonstrates an improvement in the infant's emotional well-being as it shows an attachment behavior, indicating a sense of security and trust. Infants with nonorganic failure to thrive often exhibit social withdrawal and disinterest in physical contact. Choice A is incorrect as it describes a lack of stranger anxiety, which is not necessarily indicative of improvement in this context. Choice B is incorrect as a wide-eyed gaze could indicate vigilance or anxiety rather than positive emotional development. Choice C is incorrect as passivity and good sleep are not specific indicators of emotional improvement. In summary, choice D is the correct answer as it reflects positive emotional progress in the infant's attachment and responsiveness to touch.