Question

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

Answer 1

Correct Answers:

Give a sponge bath until the cord stump falls off.

Rationale :

✍️ Newborns should receive sponge baths until the umbilical cord stump falls off—usually within 10–14 days.

✍️ Immersing the stump in water increases the risk of infection or delayed drying.

✍️ The area should be kept clean and dry, with diapers folded below the stump to avoid irritation.

✍️ Products like alcohol or petroleum jelly are not recommended, as they may delay cord separation.

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Answer 2

Correct Answers:

Place the client in the lateral position.

Rationale :

👉 The described pattern is a late deceleration, which is a sign of uteroplacental insufficiency.

👉 The first intervention is to reposition the client laterally, improving placental blood flow.

👉 Oxygen, fluids, and leg elevation may follow, but position change is the immediate priority.

👉 This helps alleviate pressure on the vena cava and restore fetal oxygenation.

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Answer 3

Correct Answers:

It promotes fetal lung maturity.

Rationale :

✳️ Betamethasone is a corticosteroid administered to pregnant clients between 24–34 weeks at risk of preterm delivery.

✳️ It accelerates fetal surfactant production, enhancing lung maturity and reducing respiratory distress after birth.

✳️ It does not affect cervical dilation or stop contractions directly.

✳️ Administering it improves outcomes in preterm infants.

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Answer 4

Correct Answers:

Encourage the client to empty her bladder every 2 hr.

Rationale :

✔️ A full bladder can impede fetal descent and worsen labor discomfort.

✔️ Encouraging the client to void regularly reduces the risk of bladder distention and promotes efficient labor progression.

✔️ Bearing down is appropriate only during the second stage of labor.

✔️ Vaginal exams should be performed only as needed to reduce infection risk after amniotomy.

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Answer 5

Correct Answers:

Report of headache

Rationale :

➡️ A persistent headache is a warning sign of severe preeclampsia, indicating possible cerebral vasospasm or increased intracranial pressure.

➡️ Other expected signs include proteinuria, visual disturbances, and elevated BP.

➡️ Tachycardia and polyuria are not typical signs of this condition.

➡️ Prompt evaluation and intervention are needed to prevent eclampsia or stroke.

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Answer 6

Correct Answers:

Amniotic fluid volume
Fetal motion
Fetal breathing

Rationale :

Amniotic fluid volume

🍃 This measures placental function and fetal well-being; oligohydramnios can suggest growth restriction or rupture.

🍃 It's a key indicator in the BPP for predicting fetal compromise.

Fetal motion

🍃 The presence of body and limb movements is a reassuring sign of fetal neurological function.

🍃 Lack of motion may require further evaluation or delivery planning.

Fetal breathing

🍃 BPP evaluates fetal respiratory movements, which reflect central nervous system maturity.

🍃 Absence may indicate hypoxia or distress.

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Answer 7

Correct Answers:

4-0-1-2-2

Rationale :

⪼ GTPAL stands for Gravida, Term, Preterm, Abortions, Living.

⪼ This client has had 4 pregnancies (G), 0 term births, 1 preterm twin birth, 2 abortions, and 2 living children.

⪼ The twin birth counts as 1 preterm delivery but 2 living children.

⪼ The correct breakdown is 4-0-1-2-2.

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Answer 8

Correct Answers:

Variable decelerations

Rationale :

◈ Variable decelerations are often caused by umbilical cord compression, leading to abrupt drops in fetal heart rate.

◈ They vary in timing and shape but are typically sharp and V- or U-shaped.

◈ Intervention includes repositioning, oxygen, or amnioinfusion if recurrent.

◈ This pattern is different from late decels (placenta) or early decels (head compression).

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Answer 9

Correct Answers:

Assist the client to turn onto her side

Rationale :

▧ A blood pressure of 82/52 mm Hg suggests supine hypotensive syndrome, often due to vena cava compression by the gravid uterus.

▧ Turning the client to the left side restores venous return and improves cardiac output and placental perfusion.

▧ Upright positioning could worsen hypotension.

▧ Delivery is not yet warranted based on cervical findings and vitals.

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Answer 10

Correct Answers:

In 3 to 5 days

Rationale :

▲ After birth, transitional milk becomes mature milk around day 3 to 5 postpartum.

▲ This timing varies slightly depending on frequency of nipple stimulation and milk removal.

▲ Colostrum is present first, followed by increased milk volume.

▲ The nurse should reassure the client this is normal and provide support for continued breastfeeding.

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QLexNursing

1 :
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

3 :
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

4 :
A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

5 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

6 :
A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

8 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

9 :
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

10 :
A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

QLexNursing

1 : A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

3 : A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

4 : A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

5 : A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

6 : A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

8 : A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

9 : A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

10 : A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

1 :
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

3 :
A nurse is admitting a client who is at 30 weeks of gestation and is in preterm labor. The client has a new prescription for betamethasone and asks the nurse about the purpose of this medication. The nurse should provide which of the following explanations?

4 :
A nurse is caring for a client following an amniotomy, who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

5 :
A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding?

6 :
A nurse is caring for a client who is to undergo a biophysical profile. The client asks the nurse what is being evaluated during this test. Which of the following should the nurse include? (Select all that apply.)

8 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

9 :
A nurse is caring for a client who is at 40 weeks gestation and is in active labor. The client has 6 cm of cervical dilation and 100% cervical effacement. The nurse obtains the client's blood pressure reading as 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?

10 :
A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?