103 Unit 1: Mixed bag Pt. 2
The nurse is talking to a pregnant client with HIV regarding care for the newborn after delivery. the client asks the nurse about feeding options that are available. Which response should the nurse make to the client? A) "You will need to bottle feed your newborn." B) "You will need to feed your newborn by nasogastric tube feeding." C) "You will be able to breastfeed for 6 months and then will need to switch to bottle." D) "You will be able to breastfeed for 9 months and then will need to switch to bottle."
A) "You will need to bottle feed your newborn." Rationale: Clients who have HIV are advised not to breastfeed
The nurse is reinforcing instruction to a new mom about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection? A) A darkened drying stump B) A moist cord with discharge C) A purple stump that shows pinkness around the base D) A purple stump that shows some moistness at the base
B) A moist cord with discharge rationale: Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base. If signs of infection occur, the primary HCP is notified. Antibiotic treatment may be necessary
The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. the priority nursing action should be to monitor which clinical parameter? A) Urinary output B) Blood glucose level C) Total bilirubin level D) Hemoglobin and hematocrit levels
B) Blood glucose level Rationale: The most common metabolic complicating in the post-term newborn is hypoglycemia, which can produce CNS abnormalities and cognitive impairment if it is not corrected immediately.
The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? A) Alcohol is the only agent used to clean the cord B) It takes 21 days for the cord to dry up and fall off C) Cord care is done only at birth to control bleeding D) The process of keeping the cord clean and dry will decrease bacterial growth
D) The process of keeping the cord clean and dry will decrease bacterial growth Rationale: The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7 to 14 days. Agents other than alcohol may be prescribed to clean the cord.
The nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? SATA A) Proteinuria B) HTN C) Low-grade fever D) Increased pulse rate E) Increased respiratory rate
A, B - Proteinuria - Hypertension Rationale: Signs of preeclampsia are hypertension and proteinuria. A low grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia.
The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? A) Tachypnea and retractions B) Acrocyanosis and grunting C) Hypotension and bradycardia D) The presence of a barrel chest with acrocyanosis
A) Tachypnea and retractions Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life.
The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? A) Begin with the eyes and face B) Start with the dirtiest area first C) Begin with the feet and work upward D) Only wash the diaper area, because this is the only part of the baby that gets soiled
A) Begin with the eyes and face Rationale: Bathing should start at the eyes and face, which are usually the cleanest areas. Next, the external portion of the ears and behind the ears are cleaned. The newborn's neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. the hands and arms are then washed. The baby's legs are washed, with the diaper area being washed last.
A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. the nurse plans to provide with information to the client? A) "You will be isolated for you baby after delivery." B) "There is little risk to your baby during your pregnancy, birth and after delivery." C) "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." D) "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a c-section will be needed."
D) "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a c-section will be needed." Rationale: If herpes genital lesions are present at the time of delivery, a c-section will be necessary to reduce the risk of infecting the baby. IN the absence of lesions, a vaginal delivery may be indicated unless there are other reasons for performing a c-section. Potentially exposed babies should be cultured on the day of delivery.
A pregnant client is seen in the clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. the nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? A) Contact the HCP B) Instruct the client to maintain bed rest for the remainder of the pregnancy C) Tell the client that these are common and they may occur throughout the pregnancy D) Call the maternity unit and inform them that the client will be admitted in a prelabor condition.
C) Tell the client that theses are common and they may occur throughout the pregnancy Rationale: Braxton Hicks contractions are irregular contractions that may occur intermittently throughout pregnancy.
The nurse administers erythromycin ointment to the newborn's eyes and the mother asks the nurse why tis is done. The nurse should give which response to the client? A) Prevents cataracts in the neonate born to a woman who is susceptible to rubella B) Protects the neonate's eyes from possible infection acquired while hospitalized C) Minimizes the spread of microorganisms to the neonate from invasive procedures during labor D) Prevents opthalmia neonatorum from occurring to a neonate born to a woman with an untreated gonococcal infection
D) Prevents opthalmia neonatorum from occurring to a neonate born to a woman with an untreated gonococcal infection Rationale: Erythromycin opthalmic ointment is used as a prophylactic treatment for ophthalmia neonatorum, which caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law.
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full0term newborn after admission to the nursery. the nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? A) A length of 19 inches B) Abnormal palmar creases C) A brith weight of 6lb 14oz D) A head circumference that is appropriate for gestational age
B) Abnormal palmar creases Rationale: Features of newborn infants who are diagnosed with FAS include: craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress.
The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first? A) Administer oxygen by face mask B) Clear and maintain an open airway C) Check the BP and and fetal heart tones D) Prepare for the administration of IV magnesium sulfate
B) Clear and maintain an open airway Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise.
The nurse is preparing to care for a newborn who is receiving phototherapy. Which measure should be implemented? SATA A) Avoid stimulation B)Decrease fluid intake C) Expose all of the newborn's skin D) Monitor the skin temperature closely E) Reposition the newborn every 2 hours F) Cover the newborn's eyes with shields or patches
D, E, F Rationale: Phototherapy is the use of intense fluorescent lights to reduce bilirubin levels in the newborn. Injury from treatment can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for the infection or irritation and to allow for eye contact. The nurse measures the quantity of light ever 8 hours, monitors the skin temp closely, and increase fluids to compensate for water loss. The newborn will have loose green stools and green colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and he/she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia, because rebound elevations are normal after therapy is discontinued.
The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3yo child who was born at 39 weeks gestation. the nurse should document which gravida and para status on this client? A) Gravida 1, para 1 B) Gravida 2, Para 1 C) Gravida 2, Para 2 D) Gravida 3, Para 2
B) Gravida 2, Para 1 Rationale: Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks gestation; it does not reflect the number of fetuses or infants.
The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last period (LMP) was October 20, 2019. Using Nagele's rule, the nurse determines the estimated date of birth is which date? A) July 12, 2020 B) July 27, 2020 C) August 12, 2020 D) August 27, 2020
B) July 27, 2020 Rationale: The accurate use of Nagele's rule requires that the woman have a regular 28 day menstrual cycle. Subtract 3 months from the fist day of the LMP, add 7 days, then adjust the year as appropriate.
The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5yo child who was delivered at 38 weeks, and she tells the nurse that she doesn't have a history of any type of abortion or fetal demise. the nurse should document which at the GTPAL for this client? A) G3, T2, P0, A0, L1 B) G2, T1, P0, A0, L1 C) G1, T1, P1, A0, L1 D) G2, T0, P0, A0, L1
B) G2, T1, P0, A0, L1 Rationale: Pregnancy outcomes can be described with the GTPAL acronym: G= gravidity (number of pregnancies); T= term births (Number born after 37 weeks); P= Preterm births (number born before 37 weeks gestation); A= abortions/miscarriages (number of abortions/miscarriages); L= Live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0 and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.
The pregnant client complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure? A) Dorsiflex the client's foot while flexing the knee B) Plantarflex the client's foot while flexing the knee C) Dorsiflex the client's foot while extending the knee D) Plantarflex the client's foot while extending the knee
C) Dorsiflex the client's foot while extending the knee Rationale: Leg cramps often occur when the pregnant woman stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping.
A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? A) "Your newborn needs vitamin K to develop immunity." B) The vitamin K will protect your newborn from becoming jaundiced." C) "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." D) "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria
C) "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." Rationale: Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the livers formation of the clotting factors. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing this fat-soluble vitamin. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of vitamin K until bacteria have adequately colonized it. the bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.
*Possible exam question* After birth the nurse prevents hypothermia as a result of evaporation by performing which action? A) Warming the crib pad B) Closing the doors of the room C) Drying the baby with a warm blanket D) Turning on the overhead radiant warmer
C) Drying the baby with a warm blanket Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry and by drying the wet newborn at birth, evaporation is prevented.
While assessing the measurement of fundal height, a client at 36 weeks gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason? A) A full bladder B) Emotional instability C) Insufficient iron intake D) Compression of the vena cava
D) Compression of the inferior vena cava Rationale: compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem.
*Possible exam question* A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing? A) Quickening B) Braxton Hicks contractions C) Consistent increase in fundal height D) Fetal HR of 180
D) Fetal HR of 180 Rationale: The FHR depends on the gestational age. It is 160-170 during the first trimester, and it slows with fetal growth to approximately 120 to 160
The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts? A) Lie on the left side with her feet dorsiflexed B) Soak the feet in hot water after performing 10 pelvic tilt exercises C) Lie on the right side with the feet elevated on a pillow and a heating pad on the back D) Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle
D) Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle Rationale: The position described in option D will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities.
