Question

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Answer 1

Correct Answers:

Cluster the newborn's care activities

Rationale :

🌸 Preterm newborns have limited energy reserves and are easily overstimulated by frequent handling.

🌸 Clustering care allows longer periods of uninterrupted sleep, which is essential for brain growth and neurologic development.

🌸 Reducing repeated stimulation supports physiologic stability, including heart rate, oxygen saturation, and temperature regulation.

🌸 Consolidated care minimizes stress responses such as desaturation and apnea.

🌸 This approach aligns with developmentally supportive neonatal care principles.

❌ Incorrect Options

🌸 Keep the newborn in a well-lit nursery.

Preterm infants require low-stimulation environments to prevent sensory overload. Excessive light can increase stress and disrupt sleep cycles.

🌸 Position the newborn to promote extension of muscles.

Preterm infants benefit from flexion positioning, which mimics the intrauterine environment. Extension increases energy expenditure and stress.

🌸 Use of fingertips when calming the newborn.

Fingertip touch can be overstimulating for preterm infants. Firm, gentle containment with the whole hand is preferred.

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Answer 2

Correct Answers:

You'll need an extra 400 to 500 calories per day while breastfeeding.

Rationale :

🟦 Breastfeeding increases maternal energy demands due to milk production.

🟦 An additional 400–500 calories per day supports adequate milk supply and maternal nutritional needs.

🟦 These extra calories help maintain maternal energy levels and nutrient stores.

🟦 Caloric needs may vary slightly based on activity level, but this range is evidence-based and widely recommended.

🟦 Adequate caloric intake supports both infant growth and maternal health during lactation.

❌ Incorrect Options:

🟦 You don’t need any extra calories while breastfeeding if you eat a balanced diet.

Breastfeeding significantly increases energy expenditure beyond baseline needs. A balanced diet alone is insufficient without added calories.

🟦 An increase of about 300 to 400 calories daily is sufficient during breastfeeding.

This range is generally recommended during pregnancy, not lactation. Breastfeeding requires higher caloric intake.

🟦 You should increase your intake by about 700 additional calories per day.

This amount exceeds typical recommendations and may lead to unnecessary weight gain.

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Answer 3

Correct Answers:

I will speak with my obstetrician at my postpartum follow-up visit. I should not have intercourse until I have had that physical examination.
My husband is getting a vasectomy. We will be using condoms until his second semen analysis is negative for sperm.

Rationale :

🟣 “I will speak with my obstetrician at my postpartum follow-up visit. I should not have intercourse until I have had that physical examination.”

✔ Appropriate understanding – NO additional education needed

🟣 This statement reflects safe postpartum decision-making and awareness of maternal recovery.

🟣 The postpartum visit allows assessment of uterine involution, lochia, perineal healing, and infection risk.

🟣 Delaying intercourse reduces the risk of hemorrhage and endometritis.

🟣 This plan also provides an opportunity to discuss contraception before resuming sexual activity.

🟣 Overall, this demonstrates appropriate health-seeking behavior.

🟣 “My husband is getting a vasectomy. We will be using condoms until his second semen analysis is negative for sperm.”

✔ Appropriate understanding – NO additional education needed

🟣 Vasectomy is not immediately effective, as sperm remain in the vas deferens for weeks to months.

🟣 Using condoms until two consecutive semen analyses confirm azoospermia is correct practice.

🟣 This approach prevents unintended pregnancy during the clearance period.

🟣 The statement demonstrates accurate understanding of male sterilization.

🟣 This reflects appropriate contraceptive planning and shared responsibility.

🟣 “I used a diaphragm prior to this pregnancy and I plan to use my old one when we start having sex again.”

❌ Needs additional education

🟣 Pregnancy and childbirth cause significant changes in cervical size, vaginal tone, and pelvic anatomy.

🟣 A diaphragm that fit before pregnancy will likely no longer fit correctly postpartum.

🟣 An improperly fitted diaphragm greatly reduces contraceptive effectiveness.

🟣 Diaphragms must be refitted at the postpartum visit before reuse.

🟣 This statement indicates lack of understanding of postpartum anatomical changes.

🟣 “I will be breastfeeding for the next 6 months. We will start using a condom after I have my first period.”

❌ Needs additional education

🟣 Ovulation can occur before the first postpartum menstrual period, even during breastfeeding.

🟣 Waiting for menses before starting contraception places the woman at high risk for unintended pregnancy.

🟣 Breastfeeding is only contraceptive under strict lactational amenorrhea method (LAM) criteria, which are often not fully met.

🟣 Many women mistakenly believe that no period equals no fertility, which is incorrect.

🟣 This statement shows misunderstanding of postpartum fertility return.

🟣 “I plan to have an intrauterine device (IUD) implanted in my arm. We will be using condoms until I get an IUD.”

❌ Needs additional education

🟣 IUDs are placed in the uterus, not the arm.

🟣 Devices placed in the arm are subdermal hormonal implants, which are a different contraceptive method.

🟣 Confusing these methods suggests misunderstanding of contraceptive types and placement.

🟣 Correct knowledge is essential to ensure appropriate consent and expectations.

🟣 This statement signals a clear educational gap.

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Answer 4

Correct Answers:

Monitor for signs of placental separation and prepare for its expulsion

Rationale :

🌼 The third stage of labor focuses on placental separation and delivery, which is the critical event during this phase.

🌼 Failure to recognize placental separation promptly can lead to retained placenta and postpartum hemorrhage.

🌼 Classic signs include a firm, globular uterus, sudden gush of blood, and lengthening of the umbilical cord.

🌼 Timely monitoring allows the nurse to prepare for controlled placental expulsion and reduce bleeding risks.

🌼 Early identification of abnormalities during this stage is essential for preventing life-threatening complications.

❌ Incorrect Options:

🌼 Assess the mother’s blood pressure and pulse every 30 minutes.

Vital signs are important but should be assessed more frequently in the immediate postpartum period. This action does not directly address third-stage complications.

🌼 Massage the uterus firmly to maintain uterine contraction.

Uterine massage is appropriate after placental delivery, not before. Massaging too early may interfere with placental separation.

🌼 Encourage the mother to begin breastfeeding immediately.

Breastfeeding is beneficial for uterine involution but is not the priority during active placental separation.

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Answer 5

Correct Answers:

Are unable to shiver effectively to increase heat production and lack subcutaneous fat to provide insulation

Rationale :

❄️ Newborns cannot shiver effectively, which limits their ability to generate heat through muscle activity.

❄️ They also have minimal subcutaneous fat, reducing insulation and increasing heat loss.

❄️ Instead of shivering, newborns rely on brown fat metabolism, which is inefficient and easily depleted.

❄️ These physiologic limitations make newborns highly vulnerable to hypothermia.

❄️ Nursing interventions such as warming, drying, and skin-to-skin contact are essential to maintain thermal stability.

❌ Incorrect Options:

❄️ Lose more body heat when they sweat than adults.

Newborns have immature sweat glands and do not lose significant heat through sweating.

❄️ Have a smaller body surface compared to body mass.

Newborns actually have a larger body surface area relative to mass, which increases heat loss.

❄️ Have an abundant amount of subcutaneous fat all over.

Newborns have limited subcutaneous fat, especially preterm infants, increasing risk for hypothermia.

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Answer 6

Correct Answers

Blank 1 Correct Option: Promethazine (Phenergan)
Blank 2 Correct Option: Nalbuphine (Nubain)

Rationale :

🟢 Promethazine (Phenergan) — Antiemetic

🟢 Promethazine is a commonly used antiemetic during labor to manage nausea and vomiting.

🟢 It works by blocking histamine and dopamine receptors, reducing stimulation of the vomiting center.

🟢 The medication also provides sedative effects, which can help promote maternal comfort.

🟢 It is frequently administered in combination with opioid analgesics during labor.

🟢 This makes promethazine an effective choice for controlling labor-associated nausea.

🔵 Nalbuphine (Nubain) — Analgesic

🔵 Nalbuphine is one of the most commonly used opioid analgesics during labor.

🔵 It is a mixed opioid agonist-antagonist, providing effective pain relief with less respiratory depression.

🔵 The medication reduces moderate to severe labor pain while maintaining maternal alertness.

🔵 Nalbuphine has a lower risk of neonatal respiratory depression compared with full opioid agonists.

🔵 Its safety profile makes it a preferred systemic analgesic in labor.

❌ Incorrect Options

🟢 Hydroxyzine (Vistaril).

Hydroxyzine may provide sedation and anxiety relief but is not the primary antiemetic used in labor. It is less effective for labor-related nausea.

🟢 Ibuprofen (Motrin).

Ibuprofen is contraindicated during labor due to effects on uterine activity and fetal circulation. It is used postpartum, not intrapartum.

🟢 Midazolam (Versed).

Midazolam is a benzodiazepine sedative, not an analgesic or antiemetic. It may cause excessive maternal and neonatal sedation.

🟢 Dilaudid.

Dilaudid is a potent opioid analgesic but is less commonly used in labor due to higher risk of respiratory depression. Nalbuphine is preferred.

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Answer 7

Correct Answers:

Softening of the cervix (Hegar's sign)
Ballottement
Positive pregnancy test

Rationale :

🟣 Softening of the cervix (Hegar’s sign) ✅ Probable sign

🟣 Hegar’s sign refers to softening of the lower uterine segment/isthmus early in pregnancy.

🟣 This change occurs due to increased vascularity and hormonal influence.

🟣 It is detected on bimanual pelvic examination by a trained examiner.

🟣 Because it is felt by the examiner, not perceived by the woman, it is classified as a probable sign.

🟣 It strongly suggests pregnancy but does not confirm fetal presence.

🟣 Ballottement ✅ Probable sign

🟣 Ballottement is the rebound of the fetus against the examiner’s fingers during pelvic examination.

🟣 It occurs when the fetus is suspended in amniotic fluid, typically after mid-pregnancy.

🟣 This finding can only be elicited by a healthcare provider.

🟣 It indicates the presence of a uterine mass consistent with pregnancy.

🟣 Because other masses could theoretically cause similar movement, it remains a probable sign, not definitive.

🟣 Positive pregnancy test ✅ Probable sign

🟣 Pregnancy tests detect human chorionic gonadotropin (hCG) in blood or urine.

🟣 hCG is usually produced by the placenta after implantation.

🟣 Certain conditions (e.g., trophoblastic disease, tumors) can cause false-positive results.

🟣 For this reason, a positive test suggests but does not absolutely confirm pregnancy.

🟣 It is therefore classified as a probable sign.

❌ Not Probable Signs

🟣 Absence of menstruation ❌ Presumptive sign

🟣 Amenorrhea is a subjective symptom reported by the woman.

🟣 It can occur due to stress, hormonal imbalance, illness, or weight changes.

🟣 Because it is not observed or verified by a clinician, it is presumptive, not probable.

🟣 Auscultation of a fetal heart beat ❌ Positive sign

🟣 Hearing a fetal heartbeat confirms the presence of a living fetus.

🟣 This finding cannot be mimicked by other conditions.

🟣 It is a definitive indicator of pregnancy and is classified as a positive sign.

🟣 Ultrasound visualization of the fetus ❌ Positive sign

🟣 Visualization of the fetus provides direct evidence of pregnancy.

🟣 It confirms fetal presence, location, and viability.

🟣 This finding is diagnostic and therefore a positive sign, not probable.

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Answer 8

Correct Answers:

Maternal age of 26

Rationale :

🟠 Maternal age of 26 is considered within the optimal reproductive age range and is not associated with increased postpartum risk.

🟠 Women between 20 and 35 years generally have lower rates of obstetric and postpartum complications.

🟠 This age group has reduced risk for uterine atony, hemorrhage, and delayed recovery compared with extremes of age.

🟠 Age alone does not negatively affect uterine tone, glucose regulation, or placental separation in this patient.

🟠 Therefore, maternal age of 26 does not contribute to postpartum complications.

❌ Incorrect Options

🟠 Retained placental fragments

Retained fragments prevent adequate uterine contraction and significantly increase the risk of postpartum hemorrhage and infection. This is a major postpartum complication risk factor.

🟠 Uterine overdistention (twins, large infant over 9 lbs.)

Overdistention reduces uterine tone and increases the risk of uterine atony and hemorrhage. A 9 lb 4 oz infant places this patient at increased risk.

🟠 History of DM including gestational onset DM

Diabetes is associated with macrosomia, poor uterine contractility, and delayed healing. These factors increase postpartum complication risk.

🟠 Prolonged labor (more than 24 hrs.)

Prolonged labor exhausts uterine muscle and increases the likelihood of uterine atony and postpartum hemorrhage. It is a well-established risk factor.

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Answer 9

Correct Answers:

Most fertilization happens in the upper third of the fallopian tube.

Rationale :

🟦 Fertilization most commonly occurs in the ampulla, which is the upper third of the fallopian tube.

🟦 This region provides the optimal environment for sperm–ovum interaction due to its anatomy and secretions.

🟦 After ovulation, the ovum enters the fallopian tube where it remains viable for about 24 hours.

🟦 Sperm can survive for several days, making fertilization most likely in this portion of the tube.

🟦 Understanding this location is essential for normal conception and ectopic pregnancy risk assessment.

❌ Incorrect Options

🟦 Fertilization usually occurs in the lower portion of the uterus.

The uterus is the site of implantation, not fertilization. Fertilization must occur before the embryo reaches the uterus.

🟦 The ovum is normally fertilized inside the ovarian follicle.

Ovulation releases the ovum from the follicle prior to fertilization. Fertilization does not occur within the ovary.

🟦 Fertilization typically occurs in the cervix before the egg enters the uterus.

The cervix serves as a passageway for sperm, not a fertilization site. It does not support ovum–sperm fusion.

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Answer 10

Correct Answers

Auscultation of fetal heart tones heard via Doppler [ Positive ]
Ultrasound verification of embryo or fetus [ Positive ]
Amenorrhea [ Presumptive ]
Fetal movement felt by experienced clinician [ Probable ]
Chadwick’s sign [ Probable ]
Positive HCG pregnancy test [ Probable ]
Fatigue, nausea and vomiting [ Presumptive ]
Breast tenderness [ Presumptive ]

Rationale :

🟡 PRESUMPTIVE SIGNS

(Subjective findings — felt by the woman; not diagnostic)

🟡 Amenorrhea

🔹 Amenorrhea refers to the absence of menstruation, often the first change noticed in early pregnancy.

🔹 It occurs because hormonal changes suppress ovulation and the menstrual cycle.

🔹 This sign is not specific to pregnancy and can result from stress, weight changes, endocrine disorders, or excessive exercise.

🔹 Breastfeeding and irregular cycles further reduce its reliability.

🔹 It is considered presumptive because it is reported by the woman and not directly observed by the examiner.

🟡 Fatigue, nausea, and vomiting

🔹 These symptoms are common in early pregnancy due to increasing hCG and progesterone levels.

🔹 Nausea and vomiting (“morning sickness”) may occur at any time of day, especially in the first trimester.

🔹 Fatigue results from increased metabolic demands and hormonal effects.

🔹 These symptoms are nonspecific and can also occur with infections, GI illness, anemia, or stress.

🔹 Because they are subjectively experienced, they are classified as presumptive signs.

🟡 Breast tenderness

🔹 Breast tenderness occurs due to estrogen and progesterone stimulation of breast tissue.

🔹 Women may report swelling, tingling, heaviness, or sensitivity early in pregnancy.

🔹 These changes prepare the breasts for lactation.

🔹 Similar symptoms can occur with premenstrual syndrome or hormonal therapy.

🔹 Since the finding is felt by the woman, it remains a presumptive sign.

🟠 PROBABLE SIGNS

(Objective findings — observed by the examiner or tests; strongly suggest pregnancy)

🟠 Chadwick’s sign

🔹 Chadwick’s sign is a bluish-purple discoloration of the cervix, vagina, and vulva.

🔹 It is caused by increased pelvic blood flow and vascular congestion during pregnancy.

🔹 This sign typically appears around 6–8 weeks of gestation.

🔹 It is detected on pelvic examination by a clinician.

🔹 It is probable because other conditions causing pelvic congestion can mimic it.

🟠 Positive hCG pregnancy test

🔹 Pregnancy tests detect human chorionic gonadotropin (hCG) in blood or urine.

🔹 hCG is produced by trophoblastic tissue after implantation.

🔹 False positives may occur with trophoblastic disease, certain tumors, or fertility medications.

🔹 False negatives may occur if testing is done too early.

🔹 Because hCG does not directly confirm a fetus, it is a probable sign, not positive.

🟠 Fetal movement felt by experienced clinician

🔹 During abdominal or pelvic examination, a clinician may feel movement within the uterus.

🔹 This movement suggests the presence of a fetus suspended in amniotic fluid.

🔹 It is more reliable than maternal quickening but still not definitive.

🔹 Intestinal activity or abdominal muscle movement may mimic fetal motion.

🔹 Therefore, it is classified as a probable sign.

🟢 POSITIVE SIGNS

(Diagnostic — direct evidence of pregnancy)

🟢 Auscultation of fetal heart tones via Doppler

🔹 Hearing fetal heart tones confirms the presence of a living fetus.

🔹 Fetal heart tones are usually detected by Doppler at 10–12 weeks gestation.

🔹 The fetal heart rate is distinct from the maternal pulse.

🔹 No other condition can produce fetal heart tones.

🔹 This finding is a positive (diagnostic) sign of pregnancy.

🟢 Ultrasound verification of embryo or fetus

🔹 Ultrasound provides direct visualization of the embryo or fetus.

🔹 It can confirm location, viability, and gestational age.

🔹 Cardiac activity may be visualized early in pregnancy.

🔹 Ultrasound eliminates uncertainty caused by subjective symptoms or indirect signs.

🔹 It is the most definitive confirmation of pregnancy, making it a positive sign.

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QLexNursing

1 :
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

❌ Incorrect Options

3 :
Which of the following statements made by a woman during discharge teaching indicate the need for additional education about contraception? (Select all that apply.)

🟣 “I will speak with my obstetrician at my postpartum follow-up visit. I should not have intercourse until I have had that physical examination.”

🟣 “My husband is getting a vasectomy. We will be using condoms until his second semen analysis is negative for sperm.”

🟣 “I used a diaphragm prior to this pregnancy and I plan to use my old one when we start having sex again.”

🟣 “I will be breastfeeding for the next 6 months. We will start using a condom after I have my first period.”

🟣 “I plan to have an intrauterine device (IUD) implanted in my arm. We will be using condoms until I get an IUD.”

4 :
A nurse is caring for a patient in the third stage of labor, following the delivery of the newborn. Which of the following nursing actions is the priority to prevent complications during this stage?

5 :
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

6 :
Patient data

Correct Answers

7 :
A woman comes to the prenatal clinic suspecting that she is pregnant, and the assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? (Select all that apply.)

8 :
A nurse is caring for a 26-year-old woman who delivered a healthy 9 lb 4 oz infant after a 26-hour labor

Answer Options

9 :
The nurse is teaching a group of clients about human reproduction. Which statement made by a client indicates an accurate understanding of where fertilization typically occurs?

10 :
Patient assessment

Correct Answers

Prompts	Presumptive	Probable	Positive
Auscultation of fetal heart tones heard via Doppler
Ultrasound verification of embryo or fetus
Amenorrhea
Fetal movement felt by experienced clinician
Chadwick’s sign
Positive HCG pregnancy test
Fatigue, nausea and vomiting
Breast tenderness

QLexNursing

1 : A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

❌ Incorrect Options

3 : Which of the following statements made by a woman during discharge teaching indicate the need for additional education about contraception? (Select all that apply.)

🟣 “I will speak with my obstetrician at my postpartum follow-up visit. I should not have intercourse until I have had that physical examination.”

🟣 “My husband is getting a vasectomy. We will be using condoms until his second semen analysis is negative for sperm.”

🟣 “I used a diaphragm prior to this pregnancy and I plan to use my old one when we start having sex again.”

🟣 “I will be breastfeeding for the next 6 months. We will start using a condom after I have my first period.”

🟣 “I plan to have an intrauterine device (IUD) implanted in my arm. We will be using condoms until I get an IUD.”

4 : A nurse is caring for a patient in the third stage of labor, following the delivery of the newborn. Which of the following nursing actions is the priority to prevent complications during this stage?

5 : The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

6 : Patient data

Correct Answers

7 : A woman comes to the prenatal clinic suspecting that she is pregnant, and the assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? (Select all that apply.)

8 : A nurse is caring for a 26-year-old woman who delivered a healthy 9 lb 4 oz infant after a 26-hour labor

Answer Options

9 : The nurse is teaching a group of clients about human reproduction. Which statement made by a client indicates an accurate understanding of where fertilization typically occurs?

10 : Patient assessment

Correct Answers

1 :
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

3 :
Which of the following statements made by a woman during discharge teaching indicate the need for additional education about contraception? (Select all that apply.)

4 :
A nurse is caring for a patient in the third stage of labor, following the delivery of the newborn. Which of the following nursing actions is the priority to prevent complications during this stage?

5 :
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

6 :
Patient data

7 :
A woman comes to the prenatal clinic suspecting that she is pregnant, and the assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? (Select all that apply.)

8 :
A nurse is caring for a 26-year-old woman who delivered a healthy 9 lb 4 oz infant after a 26-hour labor

9 :
The nurse is teaching a group of clients about human reproduction. Which statement made by a client indicates an accurate understanding of where fertilization typically occurs?

10 :
Patient assessment