Question

A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

Answer 1

Correct Answers:

Lecithin/sphingomyelin (LIS) ratio of 2:1

Rationale :

🟢 The lecithin/sphingomyelin (L/S) ratio is a component of amniotic fluid testing used to assess fetal lung maturity, especially when early delivery is being considered.

🟢 A ratio of 2:1 or higher indicates that the fetal lungs have likely developed sufficient surfactant, which is essential for alveolar stability and effective gas exchange after birth.

🟢 Surfactant production increases significantly after 32–34 weeks gestation, and an L/S ratio of 2:1 typically corresponds to mature lungs by 35 weeks.

🟢 This is the most direct biochemical indicator of pulmonary maturity, which supports the safe timing of elective cesarean delivery when there's no labor onset.

🟢 Other findings, like a reactive NST or BPP score, assess fetal well-being but do not confirm surfactant sufficiency or pulmonary maturity.

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Answer 2

Correct Answers:

Give the newborn a sponge bath until the cord stump falls off.

Rationale :

🟡 The nurse should instruct parents to give the newborn sponge baths rather than submerging them in water until the umbilical cord stump falls off, usually within 10 to 14 days after birth.

🟡 Keeping the stump dry and exposed to air helps promote natural drying and separation and reduces the risk of infection or delayed healing.

🟡 Parents should avoid applying substances like petroleum jelly, alcohol, or soap, as these can irritate the area or interfere with the natural healing process.

🟡 The diaper should be folded below the cord stump, not over it, to prevent friction, contamination from urine, and moisture retention.

🟡 Signs of infection—such as foul odor, redness, or pus—should be reported immediately, but routine gentle cleaning and air drying are usually sufficient.

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Answer 3

Correct Answers:

The purpose of this medication is to boost fetal lung maturity.

Rationale :

🟢 Betamethasone is a corticosteroid administered to pregnant clients between 24 and 34 weeks of gestation who are at risk for preterm delivery.

🟢 Its primary function is to accelerate fetal lung maturity by stimulating surfactant production, which reduces the risk of respiratory distress syndrome (RDS) in preterm newborns.

🟢 Surfactant helps keep the alveoli open during breathing, and without sufficient levels, preterm infants may struggle with oxygenation and require intensive respiratory support.

🟢 The medication is given as 2 intramuscular injections 24 hours apart, and optimal benefits occur within 24 to 48 hours after the last dose.

🟢 Betamethasone does not stop labor contractions or cervical dilation, and it is not intended to affect fetal heart rate.

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Answer 4

Correct Answers:

Clear the respiratory tract.

Rationale :

🔴 The priority action immediately after birth is to ensure a patent airway by clearing the newborn’s respiratory tract, typically using a bulb syringe to suction the mouth first, then the nose.

🔴 This step helps remove amniotic fluid, mucus, or meconium that may obstruct breathing and supports the newborn’s transition to extrauterine respiration.

🔴 Once the airway is clear, the nurse can proceed with stimulating the infant to cry, drying, and covering the head to prevent heat loss.

🔴 Airway clearance is part of the initial steps in neonatal resuscitation, following the ABC (Airway, Breathing, Circulation) priority framework.

🔴 Failure to clear the airway effectively may result in hypoxia, apnea, or delayed adaptation, especially in infants with thick secretions or meconium-stained fluid.

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Answer 5

Correct Answers:

Precipitous birth

Rationale :

🔴 A precipitous birth, defined as labor and delivery that occurs in less than 3 hours, is a significant risk factor for postpartum hemorrhage (PPH) due to ineffective uterine contractions following the rapid delivery.

🔴 The uterus may become fatigued or not contract adequately (uterine atony), which is the leading cause of PPH, especially when the uterus hasn't had time to contract gradually during a longer labor.

🔴 Additionally, rapid births increase the risk of perineal trauma, lacerations, and retained placental fragments, which can all contribute to hemorrhage.

🔴 Other listed factors—such as gestational hypertension, small-for-gestational-age newborn, or a two-vessel cord—do not directly cause or significantly elevate the risk of postpartum hemorrhage like a precipitous labor does.

🔴 Nurses should monitor uterine tone and vaginal bleeding closely after a rapid delivery and be prepared to intervene quickly if signs of hemorrhage occur.

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Answer 6

Correct Answers:

Do not immerse the newborn's abdomen in water until the cord is dry.

Rationale :

🟢 The nurse should teach the parent to avoid tub baths or immersing the newborn in water until the umbilical cord stump has dried and fallen off, which helps prevent infection and delayed healing.

🟢 Until then, parents should give sponge baths and keep the cord area clean, dry, and exposed to air to promote natural drying and separation.

🟢 Immersing the cord stump in water increases moisture and risk of bacterial growth, which can lead to omphalitis (cord infection) or foul-smelling drainage.

🟢 The stump typically falls off within 10 to 14 days, not necessarily by day 10–12 exactly, so care should continue until full separation and healing.

🟢 Parents should also avoid applying substances like baby oil, alcohol, or ointments, as these can interfere with natural drying and are not evidence-based for improving outcomes.

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Answer 7

Correct Answers:

Pelvic pain

Rationale :

🔴 Pelvic or lower abdominal pain is a classic and early sign of ectopic pregnancy, which occurs when a fertilized ovum implants outside the uterus, most commonly in a fallopian tube.

🔴 The pain may be unilateral, sharp, or stabbing, and can worsen if the tube ruptures, leading to referred shoulder pain and signs of hypovolemic shock.

🔴 Other early signs may include light vaginal bleeding or spotting, but copious bleeding is not typical unless rupture occurs.

🔴 Severe nausea and vomiting are more characteristic of conditions like hyperemesis gravidarum, and uterine enlargement beyond gestational age is typically associated with molar pregnancy, not ectopic implantation.

🔴 Prompt identification of pelvic pain with a positive pregnancy test and empty uterus on ultrasound is key to diagnosing and managing ectopic pregnancy to prevent tubal rupture and hemorrhage.

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Answer 8

Correct Answers:

Fetal position is persistent occiput posterior.

Rationale :

🔴 A persistent occiput posterior (OP) position means the baby’s head is down, but facing the mother’s abdomen instead of her spine.

🔴This position is one of the most common causes of difficult and prolonged labor.

🔴 In this position, the fetal head puts more pressure on the maternal sacrum, causing severe back pain, often referred to as “back labor.”

🔴 The mechanism of labor is less efficient because the fetal head has a harder time navigating through the maternal pelvis, leading to longer first and second stages of labor.

🔴 In contrast, a longitudinal lie, general flexion attitude, and gynecoid pelvis are favorable factors for labor progression and do not contribute to labor dystocia.

🔴 Management often includes position changes (e.g., hands and knees), counterpressure, or possible operative delivery if descent is impaired.

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Answer 9

Correct Answers:

A large amount of bright red vaginal bleeding without pain

Rationale :

🟥 Placenta previa is a condition in which the placenta partially or completely covers the cervical os, and it classically presents with painless, bright red vaginal bleeding in the second or third trimester.

🟥 The bleeding occurs as the cervix begins to dilate or efface, causing disruption of the placental attachment at the lower uterine segment.

🟥 Unlike placental abruption, placenta previa does not typically cause abdominal pain, and the uterus remains soft and non-tender.

🟥 Monitoring for the amount and pattern of bleeding is critical because placenta previa increases the risk of hemorrhage, preterm birth, and need for cesarean delivery.

🟥 The nurse should avoid vaginal exams, monitor fetal heart rate and maternal vital signs, and prepare for possible emergency delivery if bleeding becomes uncontrolled.

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Answer 10

Correct Answers:

Newborns lack the necessary muscle control to regulate eye movement.

Rationale :

🟢 A therapeutic response provides accurate, reassuring, and developmentally appropriate information.

🟢Newborns commonly appear to have intermittent strabismus (crossed eyes) due to immature extraocular muscles.

🟢 This condition is normal in the early newborn period, especially in the first 2 to 3 months of life, as visual coordination gradually improves with neuromuscular development.

🟢 By explaining that this is a temporary and expected finding, the nurse educates and comforts the parent while promoting confidence in newborn development.

🟢 The nurse should continue routine observation and reassure that if the condition persists beyond 2 to 3 months, further evaluation by a provider may be needed.

🟢 There is no need for immediate treatment or concern unless the strabismus is constant or present beyond the typical developmental window.

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QLexNursing

1 :
A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

2 :
A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

3 :
A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

4 :
A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

5 :
A nurse is reviewing the medical record of a client who experienced a vaginal birth 2hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

6 :
A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include?

7 :
A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

8 :
A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

9 :
A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

10 :
A client is concerned that her newborn has "crossed eyes." Which of the following statements is a therapeutic response by the nurse?

QLexNursing

1 : A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

2 : A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

3 : A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

4 : A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

5 : A nurse is reviewing the medical record of a client who experienced a vaginal birth 2hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

6 : A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include?

7 : A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

8 : A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

9 : A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

10 : A client is concerned that her newborn has "crossed eyes." Which of the following statements is a therapeutic response by the nurse?

1 :
A nurse is assisting in the care of a client who is scheduled for a cesarean birth based on the fetal lungs having reached maturity. Which of the following findings indicates that the fetal lungs are mature?

2 :
A nurse is reinforcing teaching with the parents of a newborn about caring for the umbilical cord stump. Which of the following instructions should the nurse include?

3 :
A nurse is assisting with the admission of a client who is in preterm labor at 30 weeks of gestation and has a new prescription for betamethasone. Which of the following statements should the nurse make?

4 :
A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the following actions should the nurse perform first?

5 :
A nurse is reviewing the medical record of a client who experienced a vaginal birth 2hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

6 :
A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include?

7 :
A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8 weeks of gestation. Which of the following findings should the nurse expect?

8 :
A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

9 :
A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

10 :
A client is concerned that her newborn has "crossed eyes." Which of the following statements is a therapeutic response by the nurse?