Nokea
Which safety measure should the nurse emphasize for newborn sleep?
- A. Place the newborn on their back to sleep
- B. Use soft bedding for comfort
- C. Co-sleep in the parent's bed
- D. Keep the room very warm
Correct Answer: A
Rationale: Placing the newborn on their back to sleep reduces the risk of sudden infant death syndrome (SIDS).
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The nurse is caring for the pregnant client at the initial prenatal visit. Which universal screenings should the nurse complete? Select all that apply.
- A. Taking the client’s blood pressure
- B. Doing a urine dipstick test for protein
- C. Doing a urine dipstick test for glucose
- D. Asking questions about domestic violence
- E. Asking questions about use of tobacco
Correct Answer: A,D,E
Rationale: BP screening should be performed at the initial prenatal visit to establish a baseline and to evaluate for actual or potential problems. Domestic violence screening should be performed at the initial prenatal visit to determine fetal and maternal risk for harm. Screening for tobacco use should be performed at the initial prenatal visit to determine fetal and maternal risk. Smoking is associated with an increased risk for spontaneous abortion, preterm labor, and low birth weight. The use of routine urine dip assessments is unreliable in detecting proteinuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for a UTI. The urine dipstick test is of insufficient sensitivity to be used as a screening tool for glycosuria and is not always considered accurate. A urine sample should be collected and a UA completed to check for the presence of glucose.
Where can the nurse expect to palpate the fundus at this time?
- A. Just above the symphysis pubis
- B. Just below the xiphoid process
- C. Near the level of the umbilicus
- D. Just below the symphysis pubis
Correct Answer: C
Rationale: At 20 weeks' gestation, the fundus is typically palpated near the level of the umbilicus, reflecting uterine growth.
The nurse is teaching the pregnant client during her first trimester. The nurse identifies that which decision is most important for her to make first?
- A. Bottle versus breastfeeding
- B. Labor and delivery location
- C. Pain management during labor
- D. Method for delivery of the baby
Correct Answer: B
Rationale: A decision regarding labor and delivery location is the priority for the client in order to properly plan for a home birth versus a hospital birth, HCP availability at the location, and type of labor and delivery settings available at the location. The decision on feeding the newborn can be made up to the time of the first feeding. The decision on pain management can be made early but can be changed up through the early stages of labor. The decision of delivery method should be made early but cannot be determined until the decision is made on labor and delivery location.
The nurse is counseling the client who is trying to become pregnant. To promote fetal health when the client is unaware of a pregnancy, the nurse should stress the inclusion of which nutrient in daily food intake?
- A. Potassium
- B. Calcium
- C. Folic acid
- D. Sodium
Correct Answer: C
Rationale: The nurse should educate the client about the need for adequate folic acid intake. Folic acid is important in preventing neural tube defects, especially during the first four weeks of fetal development. Potassium is important in preventing leg cramps during pregnancy, but this is usually not an issue during the first four weeks of gestation. Calcium is important for fetal development of bones, teeth, heart, nerves, and muscles, but the fetus will take calcium from the mother. Calcium is more important to maternal health than fetal development. Sodium is important for maintaining optimal electrolyte balance but is typically ingested in more than adequate amounts in a typical diet.
The pregnant client has been pushing for 2½ hours. After some difficulty, the large fetal head emerges. The HCP attempts to deliver the shoulders without success. Place the nurse’s actions in caring for this client in the correct sequence.
- A. Apply suprapubic pressure per direction of the HCP.
- B. Place the client in exaggerated lithotomy position.
- C. Catheterize the client’s bladder.
- D. Call for the neonatal resuscitation team to be present.
- E. Prepare for an emergency cesarean birth.
Correct Answer: D,B,A,C,E
Rationale: Call for the neonatal resuscitation team to be present because of fetal distress. Place the client in exaggerated lithotomy position so the McRoberts’ maneuver can be performed (flexing her thighs sharply on her abdomen may widen the pelvic outlet and let the anterior shoulder be delivered). Apply suprapubic pressure per direction of the HCP. This is completed in an effort to dislodge the shoulder from under the pubic bone. Catheterize the client’s bladder. This will empty the bladder to make more room for the fetal head. Prepare for an emergency cesarean birth. This will be performed if all efforts for a vaginal birth fail.