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NACE Care of the childbearing family
NACE Care of the childbearing family
Total Questions : 95
Showing 10 questions Sign up for moreA 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?
Explanation
The correct answer is choice D. Gestational age of 35-38 weeks.
This is because preterm babies are more likely to develop jaundice due to their immature liver and increased breakdown of red blood cells.Babies born between 35 and 38 weeks are considered late preterm and have a higher risk of jaundice than full-term babies.
Choice A is wrong because African American ethnicity is not a risk factor for jaundice.In fact, Asian, European, or native American ethnicity are more associated with jaundice.
Choice B is wrong because meconium-stained amniotic fluid is not a risk factor for jaundice.
Meconium is the first stool of the baby and it may indicate fetal distress, but it does not affect the bilirubin level.
Choice C is wrong because bottle feeding is not a risk factor for jaundice.In fact, breastfeeding is more associated with jaundice due to dehydration and poor caloric intake.
A baby boy is circumcised on the day of discharge. Which observation should the nurse make prior to the infant’s discharge?.
Explanation
This is because circumcision is a surgical procedure that involves cutting off the foreskin of the penis, which may affect the urinary function of the baby.The nurse should make sure that the baby can urinate normally and without pain after the circumcision.
The amount of urine should be adequate for the baby’s weight and hydration status.
Choice B is wrong because the erectile ability of the penis is not affected by circumcision and is not a priority for discharge planning.
Choice C is wrong because the position of the urethral opening on the penis is not related to circumcision and should be assessed at birth, not at discharge.
Choice D is wrong because the presence of a small amount of white-yellow exudate around the glans tissue is normal and expected after circumcision.It is part of the healing process and does not indicate infection.The nurse should instruct the parents on how to care for the circumcised penis and when to seek medical attention if there are signs of complications.
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?
Explanation
The correct answer is choice B. Test the patient’s vaginal secretions with nitrazine paper.
This is because the patient may be leaking amniotic fluid rather than urine, and nitrazine paper can help differentiate between the two by testing the pH level.Amniotic fluid is alkaline and will turn the paper blue, while urine is acidic and will turn the paper yellow.
Choice A is wrong because checking the patient’s bladder for distention will not help determine if the patient is leaking amniotic fluid or urine.
Choice C is wrong because checking the patient’s urine for glucose content will not help determine if the patient is leaking amniotic fluid or urine.
Glucose content may be elevated in patients with gestational diabetes, but this is not related to the patient’s complaint.
Choice D is wrong because obtaining a specimen of the patient’s vaginal secretions for culture will not help determine if the patient is leaking amniotic fluid or urine.
Culture may be done to check for infections, but this is not the initial action that the nurse should take.
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?
Explanation
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.
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?
Explanation
The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.
Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.
Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.
Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.
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?
Explanation
This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.
The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.
Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.
However, this is not related to epidural anesthesia.
Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).
However, this is not related to epidural anesthesia.
Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.
Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.
A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?
Explanation
The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.
This is a serious side effect that needs to be monitored closely by the nurse.
Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.
The Babinski reflex is a normal response in infants, but abnormal in adults.
It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.
Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.
Choice C is wrong because tetany is not a side effect of magnesium sulfate.
Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.
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?
Explanation
The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.
This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.
The duration is measured from the start of one contraction until the end of that same contraction.
Choice A is wrong because it measures the frequency of contractions, not the duration.
The frequency is the time between the start of one contraction and the start of the next one.
Choice B is wrong because it measures only half of the duration of a contraction.
The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.
Choice D is wrong because it measures both the duration and the interval of contractions.
The interval is the time between the end of one contraction and the start of the next one.
Normal ranges for contractions during labor are:
• Duration: 30 to 90 seconds
• Frequency: 2 to 5 minutes apart
• Interval: 30 to 120 seconds
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?
Explanation
The correct answer is choice B. Syphilis.A negative rapid plasma reagin (RPR) test indicates that a patient is probably not infected with syphilis, a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum.The RPR test works by detecting the nonspecific antibodies that your body produces while fighting the infection.
Choice A is wrong because herpes simplex II is a viral infection that causes genital herpes, and it is not detected by the RPR test.
Choice C is wrong because gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae, and it is also not detected by the RPR test.
Choice D is wrong because condylomata are genital warts caused by human papillomavirus (HPV), and they are not detected by the RPR test either.
The RPR test is a screening test, and it can give false-positive results due to other conditions or infections.Therefore, a positive RPR test should always be confirmed by a more specific treponemal test, such as TPPA or FTA-ABS.The RPR test can also be used to monitor the treatment response of syphilis, as the antibody levels should decrease after effective antibiotic therapy.
A patient comes to the family planning clinic requesting information.Which information should the nurse obtain initially to determine the patient’s knowledge base?.
Explanation
The correct answer is choice C. The reason for the patient’s visit at this time.
This information will help the nurse assess the patient’s motivation, readiness, and urgency for contraception.
It will also help the nurse tailor the education and counseling to the patient’s specific needs and preferences.
Choice A is wrong because the amount of sexual experience that the patient has had is not relevant to determine the patient’s knowledge base.
It may also make the patient feel uncomfortable or judged.
Choice B is wrong because the type of contraceptive that the patient’s friends are using is not a reliable source of information.
Different methods may have different advantages and disadvantages for different people.
The nurse should provide evidence-based information and guidance on various options.
Choice D is wrong because the method of contraception that the patient believes will provide protection from sexually transmitted diseases may not be accurate or effective.
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