Question

A nurse is explaining physiological jaundice to a nursing student.Which of the following should the nurse include when discussing risk factors for neonatal physiological jaundice?

Answer 1

Correct Answers:

Gestational age of 35-38 weeks.

Rationale :

🟡 Physiological jaundice is common in newborns due to immature liver function, leading to a delayed ability to conjugate and excrete bilirubin.

🟡 Late preterm infants (gestational age 35–38 weeks) are at higher risk because their hepatic enzyme systems are not fully developed, making bilirubin processing less efficient.

🟡 These infants also may have poor feeding, contributing to slower meconium excretion, which delays bilirubin elimination.

🟡 Recognizing gestational age as a risk factor helps guide early monitoring and intervention to prevent complications such as hyperbilirubinemia and kernicterus.

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Answer 2

Correct Answers:

The time and amount of the first post-procedure voiding.

Rationale :

🟢 After circumcision, it is critical to observe for the infant’s first void, as edema or trauma to the urethral meatus could cause urinary retention or obstruction.

🟢 Ensuring the baby has urinated at least once post-procedure confirms that the urinary system is intact and that there are no complications interfering with urine flow.

🟢 This assessment is necessary before discharge to prevent missed signs of urinary blockage or discomfort that may arise at home.

🟢 While mild exudate and glans healing are expected, voiding confirms functional recovery and safe transition to home.

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Answer 3

Correct Answers:

The time and amount of the first post-procedure voiding.

Rationale :

🟢 After circumcision, it is critical to observe for the infant’s first void, as edema or trauma to the urethral meatus could cause urinary retention or obstruction.

🟢 Ensuring the baby has urinated at least once post-procedure confirms that the urinary system is intact and that there are no complications interfering with urine flow.

🟢 This assessment is necessary before discharge to prevent missed signs of urinary blockage or discomfort that may arise at home.

🟢 While mild exudate and glans healing are expected, voiding confirms functional recovery and safe transition to home.

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Answer 4

Correct Answers:

Test the patient’s vaginal secretions with nitrazine paper.

Rationale :

🟢 The patient’s report of leaking fluid for 10 hours could indicate rupture of membranes (ROM) rather than urine leakage.

🟢 The initial nursing action is to use nitrazine paper to test the vaginal secretions. Amniotic fluid is alkaline and will turn the nitrazine paper blue, while urine or normal vaginal secretions are more acidic and turn it yellow.

🟢 Confirming ROM is critical to assess for the risk of infection (e.g., chorioamnionitis) and determine next steps in labor management.

🟢 Other options (like bladder check, cultures, or urine testing) are less immediate or relevant without confirming whether the fluid is indeed amniotic.

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Answer 5

Correct Answers:

“Have you noticed any tenderness in your breasts?”.

Rationale :

🟢 Breast tenderness is a common presumptive sign of early pregnancy, caused by hormonal changes (especially increased estrogen and progesterone) that prepare the body for breastfeeding.

🟢 This symptom may appear as early as the first few weeks after conception, along with other presumptive signs like nausea, fatigue, and missed periods.

🟢 Asking about breast changes helps assess whether the client is experiencing early physical indicators of pregnancy.

🟢 While spotting may occur, it can also signal complications, and shortness of breath or loss of consciousness are not typical early signs of pregnancy.

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Answer 6

Correct Answers:

Dryness and flaking of the skin on the hands and feet.

Rationale :

🟠 A newborn at 42 weeks gestation is considered post-term and typically shows signs of skin maturation, including dry, peeling, and cracking skin, especially on the hands and feet.

🟠 This occurs due to loss of protective vernix caseosa and prolonged exposure to amniotic fluid, which diminishes after 40 weeks.

🟠 Other post-term findings may include overgrown nails, decreased lanugo, and a long, thin body appearance due to wasting of subcutaneous fat.

🟠 In contrast, abundant vernix, lanugo, and minimal sole creases** are features of preterm or early-term infants.

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Answer 7

Correct Answers:

Monitor the patient’s blood pressure.

Rationale :

🔴 One of the most common and significant side effects of epidural anesthesia is maternal hypotension, which can lead to decreased uteroplacental perfusion and fetal distress.

🔴 Epidurals cause vasodilation by blocking sympathetic nerves, reducing systemic vascular resistance and potentially causing a sudden drop in blood pressure.

🔴 Frequent blood pressure monitoring (often every 5 minutes immediately after administration) is essential to detect and manage hypotension quickly.

🔴 Management may include IV fluids, repositioning, oxygen, and vasopressors as needed to maintain maternal and fetal stability.

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Answer 8

Correct Answers:

Decreased respirations.

Rationale :

🔵 Magnesium sulfate is a central nervous system depressant used in obstetrics for conditions like preeclampsia to prevent seizures, and to relax uterine muscles.

🔵 A key side effect of magnesium toxicity is respiratory depression, typically occurring when serum magnesium levels exceed 7–10 mEq/L.

🔵 The nurse must closely monitor respiratory rate, deep tendon reflexes, and urinary output, as all can reflect early signs of toxicity.

🔵 If respirations fall below 12/min, the medication may need to be held, and calcium gluconate, the antidote, should be kept readily available.

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Answer 9

Correct Answers:

Count the time from the beginning of one contraction to the end of the same contraction.

Rationale :

🟢 Contraction duration refers to how long a single contraction lasts and is measured from the beginning (onset) of the contraction to its end (return to baseline).

🟢 On the fetal monitor strip, this is seen as the rise, peak, and fall of the contraction wave.

🟢 Accurate assessment of contraction duration is essential for evaluating uterine activity, labor progression, and the fetus's ability to tolerate labor.

🟢 Duration, along with frequency and intensity, helps guide safe labor management and identify risks like tachysystole or fetal distress.

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Answer 10

Correct Answers:

Syphilis.

Rationale :

🟢 The Rapid Plasma Reagin (RPR) test is a non-treponemal blood test specifically used to screen for syphilis, a sexually transmitted infection caused by Treponema pallidum.

🟢 A negative RPR result usually indicates that the patient is not currently infected with syphilis, although early primary syphilis or late latent stages may occasionally yield false negatives.

🟢 The test detects nonspecific antibodies that are present in response to cellular damage from the syphilis organism.

🟢 RPR does not detect other STIs like herpes simplex virus (HSV II), gonorrhea, or condylomata acuminata (genital warts).

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QLexNursing

1 :
A nurse is explaining physiological jaundice to a nursing student.Which of the following should the nurse include when discussing risk factors for neonatal physiological jaundice?

2 :
A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

3 :
A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

4 :
A patient who is 38 weeks pregnant is admitted to the hospital in active labor. On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?

5 :
A nurse is caring for a female client who suspects she is pregnant. Which question, if asked by the nurse, is consistent with signs of early pregnancy?

6 :
A nurse is caring for a newborn with a gestational age of 42 weeks. Which finding would the nurse expect during the assessment of this newborn?

7 :
A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction. The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?

8 :
A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

9 :
A nurse is caring for a patient who is in labor and is placed on a monitor. How should the nurse determine the duration of contractions?

10 :
A nurse is caring for a patient being evaluated for sexually transmitted infection (STI).A negative rapid plasma reagin (RPR) indicates that a patient is probably not infected with which STI?

QLexNursing

1 : A nurse is explaining physiological jaundice to a nursing student.Which of the following should the nurse include when discussing risk factors for neonatal physiological jaundice?

2 : A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

3 : A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

4 : A patient who is 38 weeks pregnant is admitted to the hospital in active labor. On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?

5 : A nurse is caring for a female client who suspects she is pregnant. Which question, if asked by the nurse, is consistent with signs of early pregnancy?

6 : A nurse is caring for a newborn with a gestational age of 42 weeks. Which finding would the nurse expect during the assessment of this newborn?

8 : A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

9 : A nurse is caring for a patient who is in labor and is placed on a monitor. How should the nurse determine the duration of contractions?

10 : A nurse is caring for a patient being evaluated for sexually transmitted infection (STI).A negative rapid plasma reagin (RPR) indicates that a patient is probably not infected with which STI?

1 :
A nurse is explaining physiological jaundice to a nursing student.Which of the following should the nurse include when discussing risk factors for neonatal physiological jaundice?

2 :
A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

3 :
A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.

4 :
A patient who is 38 weeks pregnant is admitted to the hospital in active labor. On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?

5 :
A nurse is caring for a female client who suspects she is pregnant. Which question, if asked by the nurse, is consistent with signs of early pregnancy?

6 :
A nurse is caring for a newborn with a gestational age of 42 weeks. Which finding would the nurse expect during the assessment of this newborn?

8 :
A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?

9 :
A nurse is caring for a patient who is in labor and is placed on a monitor. How should the nurse determine the duration of contractions?

10 :
A nurse is caring for a patient being evaluated for sexually transmitted infection (STI).A negative rapid plasma reagin (RPR) indicates that a patient is probably not infected with which STI?