Question

A nurse is reinforcing teaching about newborn care with a client who is 2 hours postpartum. Which of the following statements by the client indicates a need for further teaching?

Answer 1

Correct Answers:

"My baby's temperature will be checked rectally every hour."

Rationale :

🟡 Rectal temperature is not routinely recommended due to risk of injury.

🟡 Axillary temperature is safer and standard for newborns.

🟡 Hourly temperature checks are excessive unless clinically indicated.

🟡 Skin-to-skin contact with a warm blanket helps regulate temperature.

🟡 Keeping the head covered and avoiding drafts prevents heat loss.

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Answer 2

Correct Answers:

Excessive uterine enlargement.

Rationale :

🟠 A hydatidiform mole is a gestational trophoblastic disease characterized by abnormal proliferation of trophoblastic tissue.

🟠 This abnormal growth causes the uterus to enlarge rapidly and excessively, often larger than expected for the gestational age.

🟠 Human chorionic gonadotropin (hCG) levels are typically elevated or rising rapidly, not dropping; elevated hCG is a key diagnostic clue.

🟠 Whitish vaginal discharge is not a typical sign of molar pregnancy.

🟠 Fetal heart rate irregularities are unlikely because a viable fetus is usually absent in complete molar pregnancies.

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Answer 3

Correct Answers:

Clients who have this disorder may have an increased risk of lipid and glucose metabolism disorders.

Rationale :

🔷 Hypothyroidism during pregnancy can disrupt normal metabolism, leading to an increased risk of lipid abnormalities and glucose intolerance, which can complicate maternal and fetal health.

🔷 Human chorionic gonadotropin (hCG) levels normally peak in the first trimester but this is not directly related to hypothyroidism diagnosis or management.

🔷 Thyroid hormone replacement dosing often requires adjustment during pregnancy due to increased metabolic demands; dosing is unlikely to remain consistent.

🔷 While fetal surveillance may be necessary later in pregnancy if complications arise, it is not routinely required in the first trimester solely due to maternal hypothyroidism.

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Answer 4

Correct Answers:

A large, deep sacral dimple above the gluteal cleft.

Rationale :

🟣 A large, deep sacral dimple located above the gluteal cleft may be a sign of an underlying spinal abnormality such as spina bifida occulta or other neural tube defects, warranting further diagnostic evaluation.

🟣 A hymenal tag and white vaginal discharge (pseudo-menstruation) are normal due to maternal hormone withdrawal.

🟣 Edema on the scalp that crosses suture lines is typical of caput succedaneum and usually resolves without intervention.

🟣 A heart murmur is common in newborns and often resolves spontaneously, but persistent murmurs may require follow-up—however, the sacral dimple is a more urgent concern.

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Answer 5

Correct Answers:

Prepare for cesarean birth.

Rationale :

🟥 Heavy vaginal bleeding at 39 weeks gestation is a red flag for serious obstetric complications, most commonly placenta previa or placental abruption, both of which can endanger maternal and fetal lives.

🟥 In cases of placenta previa, the placenta partially or completely covers the cervix, making a vaginal delivery unsafe due to the risk of severe hemorrhage.

🟥Cesarean birth is typically required.

🟥 Performing a cervical examination is contraindicated when placenta previa is suspected, as it can trigger or worsen bleeding.

🟥 Magnesium sulfate is used to manage preeclampsia/eclampsia, not hemorrhage.

🟥 Antibiotics are not first-line treatment unless there is evidence of infection; immediate focus should be on stabilizing the mother and preparing for delivery.

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Answer 6

Correct Answers:

Polyphagia.

Rationale :

🟠 Polyphagia (excessive hunger) is a classic symptom of uncontrolled type 1 diabetes mellitus (PDM) caused by the inability of cells to utilize glucose effectively, leading to increased hunger despite hyperglycemia.

🟠 During pregnancy, insulin needs often decrease in the first trimester due to increased insulin sensitivity, not increase, so a need for increased dosage in the first trimester is not typical.

🟠 Hypotension is not commonly associated with PDM; in fact, hypertension is more commonly observed in diabetes-related pregnancy complications.

🟠 Weight gain may be variable; however, excessive weight gain is more common in gestational diabetes and not specifically associated with type 1 PDM.

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Answer 7

Correct Answers:

Placenta previa.

Rationale :

🟥 Painless, bright red vaginal bleeding in the third trimester is a classic sign of placenta previa, where the placenta partially or completely covers the cervical opening.

🟥 This condition leads to bleeding when the cervix begins to dilate or efface because the placenta is disrupted but without uterine contractions, so pain is absent.

🟥 Threatened abortion occurs earlier in pregnancy and often presents with cramping and bleeding.

🟥 Abruptio placentae involves painful bleeding due to premature separation of the placenta and is usually accompanied by uterine tenderness and contractions.

🟥 Preterm labor involves contractions and possible cervical changes but is not defined by painless bright red bleeding.

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Answer 8

Correct Answers:

Check the fetal heart rate pattern.

Rationale :

🔷 Amniotomy is the artificial rupture of membranes to induce or augment labor.

🔷 The priority nursing action immediately following amniotomy is to assess the fetal heart rate (FHR) because rupture of membranes can increase the risk of cord prolapse or compression, which can cause fetal distress.

🔷 Early detection of abnormal FHR patterns allows for prompt intervention to prevent hypoxia.

🔷 Although monitoring for infection and evaluating the amniotic fluid’s color and consistency are important, these are secondary to ensuring fetal well-being immediately after the procedure.

🔷 Taking the maternal temperature is essential but typically done at routine intervals to monitor for infection rather than immediately post-amniotomy.

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Answer 9

Correct Answers:

Tranexamic acid.

Rationale :

🟥 Tranexamic acid is an antifibrinolytic medication that helps reduce excessive postpartum bleeding by promoting blood clot stability.

🟥 It is used to manage postpartum hemorrhage (PPH) by inhibiting the breakdown of fibrin clots, thereby decreasing bleeding.

🟥 Magnesium sulfate is used primarily for seizure prophylaxis in preeclampsia and does not control bleeding.

🟥 Betamethasone is administered antenatally to enhance fetal lung maturity, not to manage bleeding.

🟥 Terbutaline is a tocolytic used to stop preterm labor contractions, unrelated to bleeding control.

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Answer 10

Correct Answers:

Single gene disorders can be traced through genetic lineage.

Rationale :

🟢 Single gene disorders are caused by mutations in one gene and often follow recognizable inheritance patterns (autosomal dominant, autosomal recessive, or X-linked).

🟢 Because of this, they can be traced through family pedigrees or genetic lineage to identify affected or carrier individuals.

🟢 Recessive disorders do not necessarily manifest in every generation; they can skip generations if individuals are carriers without symptoms.

🟢 Genetic disorders are not always inherited; some arise from new mutations (de novo) or environmental factors.

🟢 While single gene disorders are individually rare, collectively they are not very prevalent but can be detected through targeted genetic testing.

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QLexNursing

1 :
A nurse is reinforcing teaching about newborn care with a client who is 2 hours postpartum. Which of the following statements by the client indicates a need for further teaching?

2 :
A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

3 :
A nurse is reinforcing teaching of a newly licensed nurse about hypothyroidism during pregnancy. Which of the following statements should the nurse reinforce in the teaching?

4 :
A nurse is collecting data on a I-day-old newborn. Which of the following findings should the nurse identify as requiring follow-up?

5 :
A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

6 :
A nurse is assisting in caring for a client who has pregestational type 1 diabetes mellitus (PDM). Which of the following findings should the nurse recognize as being associated with this condition?

7 :
A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

8 :
A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

9 :
A nurse is assisting in the care of a client who gave birth 1 hour ago and is experiencing excessive vaginal bleeding. Which of the following medications should the nurse anticipate the provider will prescribe?

10 :
A nurse is reinforcing teaching to a group of clients about genetic disorders. Which of the following statements should the nurse include in the education reinforcement?

QLexNursing

1 : A nurse is reinforcing teaching about newborn care with a client who is 2 hours postpartum. Which of the following statements by the client indicates a need for further teaching?

2 : A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

3 : A nurse is reinforcing teaching of a newly licensed nurse about hypothyroidism during pregnancy. Which of the following statements should the nurse reinforce in the teaching?

4 : A nurse is collecting data on a I-day-old newborn. Which of the following findings should the nurse identify as requiring follow-up?

5 : A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

6 : A nurse is assisting in caring for a client who has pregestational type 1 diabetes mellitus (PDM). Which of the following findings should the nurse recognize as being associated with this condition?

7 : A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

8 : A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

9 : A nurse is assisting in the care of a client who gave birth 1 hour ago and is experiencing excessive vaginal bleeding. Which of the following medications should the nurse anticipate the provider will prescribe?

10 : A nurse is reinforcing teaching to a group of clients about genetic disorders. Which of the following statements should the nurse include in the education reinforcement?

1 :
A nurse is reinforcing teaching about newborn care with a client who is 2 hours postpartum. Which of the following statements by the client indicates a need for further teaching?

2 :
A nurse is caring for a client who might have a hydatidiform mole. The nurse should monitor the client for which of the following findings?

3 :
A nurse is reinforcing teaching of a newly licensed nurse about hypothyroidism during pregnancy. Which of the following statements should the nurse reinforce in the teaching?

4 :
A nurse is collecting data on a I-day-old newborn. Which of the following findings should the nurse identify as requiring follow-up?

5 :
A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take?

6 :
A nurse is assisting in caring for a client who has pregestational type 1 diabetes mellitus (PDM). Which of the following findings should the nurse recognize as being associated with this condition?

7 :
A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse recognizes this finding as an indication of which of the following conditions?

8 :
A nurse is assisting in the care of a client who is to undergo an amniotomy. Which of the following is the priority nursing action following this procedure?

9 :
A nurse is assisting in the care of a client who gave birth 1 hour ago and is experiencing excessive vaginal bleeding. Which of the following medications should the nurse anticipate the provider will prescribe?

10 :
A nurse is reinforcing teaching to a group of clients about genetic disorders. Which of the following statements should the nurse include in the education reinforcement?