A client is admitted to the hospital with severe preeclampsia. The nurse is assessing for clonus. Which of the following actions should the nurse perform?

Correct Answer: C

Rationale: In the assessment of clonus in a client with severe preeclampsia, the correct action for the nurse to perform is to dorsiflex the woman's foot (Option C). Clonus is characterized by repetitive, rhythmic contractions and relaxations of a muscle. By dorsiflexing the foot, the nurse can elicit this response in the client, which is indicative of neurological hyperactivity associated with conditions like preeclampsia. Option A, striking the woman's patellar tendon, is incorrect as this action tests for deep tendon reflexes, not clonus. Palpating the woman's ankle (Option B) does not elicit a response related to clonus. Positioning the woman's feet flat on the floor (Option D) is also not directly related to assessing clonus. Educationally, understanding the specific assessment techniques for conditions like preeclampsia is crucial for nurses caring for pregnant clients. Proper assessment skills can help in early detection of complications, leading to timely interventions and improved outcomes for both the mother and the baby. Practicing and mastering these assessment techniques is vital for providing safe and effective care in maternal health settings.

Correct Answer: B

Rationale: In the context of maternal diseases during pregnancy, understanding the causes of pathologic hyperbilirubinemia is crucial for healthcare providers to provide optimal care to pregnant individuals and their babies. The correct answer is B) Hemolytic disorders. Hemolytic disorders, such as Rh incompatibility or ABO incompatibility, can lead to the destruction of red blood cells in the fetus, resulting in an increased production of bilirubin. This excess bilirubin can overwhelm the baby's liver's ability to process it, leading to pathologic hyperbilirubinemia. Option A) Hepatic disease is incorrect because while liver dysfunction can contribute to elevated bilirubin levels, it is not the most common cause during pregnancy. Option C) Postmaturity is incorrect as it refers to a condition where a pregnancy extends beyond 42 weeks, which can increase the risk of complications but is not directly related to hyperbilirubinemia. Option D) Congenital heart defect is incorrect as it does not typically cause pathologic hyperbilirubinemia in the newborn. Educationally, understanding the etiology of pathologic hyperbilirubinemia in newborns allows healthcare providers to identify at-risk infants promptly and provide appropriate monitoring and treatment to prevent complications such as kernicterus. This knowledge is vital for nurses, midwives, and physicians involved in maternal-fetal care to ensure positive outcomes for both the mother and the baby.

Correct Answer: D

Rationale: In the case of a newborn diagnosed with a diaphragmatic hernia, the most appropriate nursing diagnosis is "D) Reduced gas exchange." This is the correct answer because a diaphragmatic hernia can lead to compression of the lungs, impacting the newborn's ability to exchange oxygen and carbon dioxide efficiently. This can result in respiratory distress and hypoxemia, making it crucial for nurses to prioritize interventions that support optimal gas exchange. Option A, "Potential for impaired parent-infant attachment," may be relevant in other situations but is not the priority in this case where the newborn's physiological needs take precedence. Option B, "Inadequate nutrition," is not directly related to the immediate concern of gas exchange. Option C, "Potential for infection," is important to consider but is not the most immediate concern compared to the compromised gas exchange in a newborn with a diaphragmatic hernia. Educationally, understanding the prioritization of nursing diagnoses based on the newborn's condition is crucial in providing safe and effective care. By focusing on the most critical issue, nurses can intervene promptly to support the newborn's respiratory function and overall well-being. This rationale highlights the importance of clinical judgment and critical thinking in nursing practice, especially in neonatal care settings.

Correct Answer: D

Rationale: In the context of maternal diseases during pregnancy, it is crucial for healthcare providers to educate parents about developmental dysplasia of the hip (DDH) screening and treatment. The correct intervention, option D, involves carefully monitoring infants for DDH at follow-up visits. This is the most appropriate action as it aligns with evidence-based practice guidelines, which recommend routine screening for DDH in newborns and ongoing monitoring during well-child visits. Regular assessments can help in early detection and timely intervention, which are crucial for successful treatment outcomes. Option A, which involves performing the Ortolani and Barlow tests, is not the most suitable intervention for parent education. These tests are typically performed by healthcare professionals to diagnose DDH, and it is not within the scope of parental responsibilities to conduct these tests. Option B, recommending double or triple diapering for added support, is not evidence-based and can potentially be harmful. This practice is outdated and can lead to hip joint stiffness and exacerbate DDH rather than providing support. Option C, explaining the need for serial casting, is also not appropriate for parent education. Serial casting is a treatment modality typically prescribed by healthcare providers for infants diagnosed with severe DDH; it is not a preventive measure that parents need to be educated about during routine screenings. Educationally, it is essential for nurses and healthcare providers to equip parents with accurate information on DDH screening, signs to watch for, and the importance of regular follow-up visits for monitoring. This empowers parents to be vigilant about their child's hip health and seek timely medical intervention if needed, ultimately contributing to better outcomes for infants with DDH.

Correct Answer: D

Rationale: The correct answer is option D: "The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth." This statement is accurate because the indirect Coombs' test is used to detect antibodies in the mother's blood that may cross the placenta and attack the baby's red blood cells, leading to hemolytic disease of the newborn. Performing this test before birth allows healthcare providers to assess the risk of hemolytic disease in the baby and take appropriate preventive measures. Option A is incorrect because Rh incompatibility can lead to hemolytic disease of the newborn even if the child is Rh-positive. If an Rh-negative mother is sensitized to Rh-positive blood, subsequent pregnancies with Rh-positive babies can be at risk. Option B is incorrect because Rh incompatibility typically results in more severe hemolytic disease compared to ABO incompatibility, which is usually milder and less likely to cause significant anemia in the newborn. Option C is incorrect because while exchange transfusions may be necessary in severe cases of hemolytic disease, they are not frequently required in all cases. Treatment options vary depending on the severity of the condition and the response to initial interventions. In an educational context, understanding the intricacies of hemolytic diseases of the newborn is crucial for healthcare providers involved in maternal and neonatal care. Knowledge of the Coombs' tests, risk factors, and treatment options is essential for the early detection and management of these conditions to prevent complications in newborns.