Question

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Answer 1

Correct Answers:

Heart rate 100/min for a 10-min period

Rationale :

🟢 Fetal heart rate below 110/min sustained for 10 minutes is considered bradycardia and is a sign of fetal distress.

🟢 Prompt reporting is needed to prevent possible fetal compromise or hypoxia.

🟢 Contractions lasting 85 seconds, a resting period of 35 seconds, or 4 contractions in 10 minutes may be within normal labor patterns, but persistent bradycardia is abnormal.

🟢 Identifying abnormal heart rate patterns can prevent serious outcomes.

🟢 Provider intervention may be required for intrauterine resuscitation or expedited delivery.

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Answer 2

Correct Answers:

Misoprostol

Rationale :

🔴 Misoprostol is a uterine stimulant and is contraindicated for labor induction in clients less than 37 weeks gestation.

🔴 It increases the risk of uterine rupture and fetal harm if used preterm.

🔴 Nifedipine and terbutaline sulfate are often used to suppress preterm labor.

🔴 Folic acid is a prenatal vitamin and not used to stimulate labor.

🔴 Medication selection must always match gestational age and indication.

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Answer 3

Correct Answers:

Dry the newborn.

Rationale :

🟣 Drying the newborn immediately prevents heat loss and reduces the risk of cold stress.

🟣 The newborn’s wet skin can quickly lose heat through evaporation.

🟣 Thermal regulation is the top priority before assessments or procedures.

🟣 Proper drying also stimulates the infant to breathe.

🟣 Identification and exams follow after stabilization.

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Answer 4

Correct Answers:

Empty her bladder immediately prior to the procedure.

Rationale :

🟡 Amniocentesis after the first trimester requires an empty bladder to avoid accidental puncture and ensure comfort.

🟡 A full bladder is only required for amniocentesis in early pregnancy to help visualize the uterus.

🟡 Fasting and enemas are not needed for this procedure.

🟡 Washing the abdomen is routine hygiene but not procedural preparation.

🟡 Safety measures prevent complications.

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Answer 5

Correct Answers:

Right lower quadrant

Rationale :

🔵 Leopold maneuvers identify fetal position; the fetal back is on the right, and the head is in the fundus.

🔵 Fetal heart tones are best auscultated through the fetal back in the lower quadrants if the head is up.

🔵 Right lower quadrant is correct for a breech presentation with the back on the right.

🔵 Accurate FHT auscultation helps assess fetal well-being.

🔵 Palpation guides monitoring and interventions.

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Answer 6

Correct Answers:

Suction the newborn's mouth with a bulb syringe.

Rationale :

🟠 Clearing the airway is the first priority when mucus is noted after birth.

🟠 Suctioning the mouth before the nose prevents aspiration.

🟠 Bulb syringe is gentle and appropriate for routine suctioning.

🟠 Deep tracheal suction is only for emergencies.

🟠 Maintaining airway patency is vital for transition to extrauterine life.

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Answer 7

Correct Answers:

Two arteries and one vein

Rationale :

🟤 Normal umbilical cord anatomy includes two arteries and one vein.

🟤 The arteries carry deoxygenated blood from the fetus to the placenta, and the vein returns oxygenated blood.

🟤 An abnormal number may indicate congenital anomalies.

🟤 The nurse should count vessels during the initial newborn assessment.

🟤 Documentation ensures awareness for future care.

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Answer 8

Correct Answers:

Placental insufficiency

Rationale :

🟢 Placental insufficiency is a major cause of a small for gestational age newborn.

🟢 It results in reduced delivery of nutrients and oxygen to the fetus.

🟢 SGA is less commonly caused by maternal obesity or primiparity.

🟢 Other causes include maternal hypertension and substance abuse.

🟢 Early detection allows for closer monitoring of fetal growth.

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Answer 9

Correct Answers:

Wide skull sutures

Rationale :

🔴 Wide skull sutures are associated with SGA due to poor fetal growth and less ossification.

🔴 SGA newborns often appear thin with loose, dry skin.

🔴 They may have a sunken abdomen, not a protruding one.

🔴 Gray umbilical cord and moist skin are not classic findings of SGA.

🔴 Recognition helps prompt appropriate care and evaluation.

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Answer 10

Correct Answers:

Newborn hypoglycemia

Rationale :

🟣 Gestational diabetes increases the risk for newborn hypoglycemia after birth due to fetal hyperinsulinemia.

🟣 Maternal glucose crosses the placenta but insulin does not, causing the fetus to produce excess insulin.

🟣 At birth, the abrupt cessation of maternal glucose can cause a rapid drop in the newborn’s blood sugar.

🟣 Monitoring glucose closely after delivery is essential.

🟣 SGA, oligohydramnios, and placenta previa are not primary complications of gestational diabetes.

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QLexNursing

1 :
A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

2 :
A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

3 :
A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

4 :
A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

6 :
A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?

7 :
A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

8 :
A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?

9 :
A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?

10 :
A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

QLexNursing

1 : A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

2 : A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

3 : A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

4 : A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

6 : A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?

7 : A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

8 : A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?

9 : A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?

10 : A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

1 :
A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

2 :
A nurse is caring for a client who is at 32 weeks of gestation and is in labor. Which of the following medications is contraindicated for this client?

3 :
A nurse is assisting with the care of a client who is in labor. Immediately after the delivery of a newborn, which of the following actions should the nurse take first?

4 :
A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

6 :
A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn's mouth and nose. Which of the following actions should the nurse take first?

7 :
A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?

8 :
A nurse is reinforcing teaching with the mother of a newborn who is small for gestational age. Which of the following should the nurse include as a cause of this condition?

9 :
A nurse is caring for a newborn who is small for gestational age. Which of the following findings is associated with this condition?

10 :
A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?