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While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?
- A. It's of no concern because it is such a small amount.
- B. The cause is usually related to swallowing blood during the delivery.
- C. Sometimes baby girls have this from hormones received from the mother.
- D. This vaginal spotting is caused by hemorrhagic disease of the newborn.
Correct Answer: C
Rationale: Pseudo-menstruation in female newborns is due to maternal hormone withdrawal.
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Following a cesarean delivery for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other deliveries were like this." The nurse's response to the client is based on the understanding of which of the following?
- A. The client will most likely have postpartum blues.
- B. Maternal-infant bonding is likely to be difficult.
- C. The client's feeling of grief is a normal reaction.
- D. This type of delivery was necessary to save the client's life.
Correct Answer: C
Rationale: Grief is a normal reaction to a complicated delivery.
During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following?
- A. Congenital anomalies.
- B. Pulmonary hypertension.
- C. Meconium aspiration syndrome.
- D. Respiratory distress syndrome.
Correct Answer: D
Rationale: Cesarean delivery, especially without labor, increases the risk of respiratory distress syndrome due to retained lung fluid. Breech presentation may exacerbate this. Congenital anomalies, pulmonary hypertension, and meconium aspiration are less directly related.
A client asks about the disadvantages of the contraceptive sponge. Which of the following would the nurse include?
- A. It is difficult to insert and remove.
- B. It provides protection against STIs.
- C. It can be left in place for up to 48 hours.
- D. It is highly effective for women who have given birth.
Correct Answer: A
Rationale: The contraceptive sponge can be difficult to insert and remove, especially for some users. It does not protect against STIs, can be left in place for up to 24 hours (not 48), and is less effective for women who have given birth due to changes in vaginal anatomy.
During the first hour after a precipitous delivery, the nurse should monitor a multiparous client for signs and symptoms of which of the following?
- A. Postpartum 'blues.'
- B. Uterine atony.
- C. Intrauterine infection.
- D. Urinary tract infection.
Correct Answer: B
Rationale: Precipitous delivery increases the risk of uterine atony due to rapid labor, potentially causing postpartum hemorrhage. Postpartum blues, intrauterine infection, or urinary tract infection are less immediate concerns.
The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks' gestation who is admitted to the birthing center in the first stage of labor. The nurse should monitor the client's fetal heart rate pattern at which of the following intervals?
- A. Every 15 minutes during the latent phase.
- B. Every 30 minutes during the active phase.
- C. Every 60 minutes during the initial phase.
- D. Every 2 hours during the transition phase.
Correct Answer: B
Rationale: For a low-risk primigravid client in the active phase of the first stage of labor, intermittent fetal heart rate monitoring is typically performed every 30 minutes to ensure fetal well-being, as per standard obstetric guidelines. More frequent monitoring (every 15 minutes) is reserved for the second stage or high-risk cases, while less frequent intervals (every 60 minutes or 2 hours) are insufficient for active labor.