The mother visits her infant in the nursery.
The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?

It is necessary to promote muscle tone to minimize acrocyanosis.

It is necessary to encourage tactile stimulation to promote the myelinization of nerves.

When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.

When reflexes are stimulated in the neonate, a normal growth pattern ensues.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother. This is based on the rooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.

Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation. It is not related to muscle tone or reflexes.

Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation. Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.

Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning. They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.

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Correct Answer is C

Explanation

This is because the first priority for a pregnant woman with acute abdominal pain is to assess the fetal well-being and rule out any obstetric complications such as placental abruption, uterine rupture, or preterm labor.Fetal heart tones can indicate the presence and viability of the fetus and alert the nurse to any signs of fetal distress or hypoxia.

Choice A: Obtain a full history is wrong because it is not the most urgent action.

A full history can provide valuable information about the possible causes of abdominal pain, but it should not delay the assessment of fetal status and maternal vital signs.

Choice B: Examine the cervix for dilation is wrong because it can be harmful in some cases.A digital cervical examination should be avoided until placenta previa is ruled out by ultrasound, as it can cause bleeding and worsen the condition.

Moreover, cervical dilation alone does not indicate the cause or severity of abdominal pain.

Choice D: Palpate for uterine contraction frequency is wrong because it is not the most reliable method to assess labor.Uterine contractions can be measured by external tocodynamometry or internal intrauterine pressure catheter, which can provide more accurate and objective data than manual palpation.

Furthermore, uterine contractions do not necessarily indicate labor, as they can also be caused by other conditions such as dehydration, infection, or irritable uterus.

A. Check the specific gravity of the amniotic fluid. B. Provide dry linens for the patient. C. Auscultate the fetal heart sounds. D. Notify the health care provider.

Correct Answer is C

Explanation

The correct answer is choice C. Auscultate the fetal heart sounds.This is because spontaneous rupture of membranes (SROM) may be associated with fetal distress or cord prolapse, and the nurse should assess the fetal well-being as soon as possible.Fetal heart sounds can indicate the presence of fetal bradycardia, tachycardia, or decelerations, which may require immediate intervention.

Choice A is wrong because checking the specific gravity of the amniotic fluid is not a priority action after SROM.The specific gravity can help differentiate amniotic fluid from urine, but it is not as reliable as other methods such as nitrazine paper test or visual inspection.

Choice B is wrong because providing dry linens for the patient is a comfort measure, but not a priority action after SROM.The nurse should first ensure the safety of the fetus and the mother before attending to their comfort needs.

Choice D is wrong because notifying the health care provider is an important action after SROM, but not the first one.The nurse should gather relevant data such as fetal heart rate, maternal vital signs, and characteristics of the fluid before contacting the provider.

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The mother visits her infant in the nursery. The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 23-year-old primigravida who appears to be in her third trimester of pregnancy comes to the labor and delivery unit reporting acute abdominal pain. She has had no prenatal care. Which assessment should the nurse do first?

Correct Answer is C

Explanation

A patient states, “My water just broke.” The nurse verifies that her membranes have ruptured spontaneously. Which action should the nurse take next?

Correct Answer is C

Explanation

A patient comes to the family planning clinic requesting information.Which information should the nurse obtain initially to determine the patient’s knowledge base?.

A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?

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?

A patient’s amniotic fluid is meconium-stained. Which action should the nurse plan to take?

The nurse provides a 16-year-old client with information concerning expected and possible changes during pregnancy. Which statement, if made by the client, would indicate that she understands the information?

A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried. My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.

Which measure should be the nurse’s priority when caring for a set of twins delivered by cesarean delivery?

A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun. A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?

The mother visits her infant in the nursery.
The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?