A nurse has just inserted an orogastric gavage tube into a preterm baby. When would the nurse determine that the tube is in the proper location?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) When gastric aspirate is removed from the tube. This is because the presence of gastric aspirate confirms that the tube is in the stomach, which is the intended location for an orogastric gavage tube. Option B) When the baby suckles on the tubing is incorrect because a baby suckling on the tubing does not provide a reliable indication of proper tube placement. It can be a dangerous assumption to rely on the baby's action to determine tube location. Option C) When respirations are unlabored during tube insertion is incorrect as it does not directly correlate with tube placement. Unlabored respirations indicate the baby's overall respiratory status, not tube location. Option D) When the tubing can be inserted no farther is incorrect because the length of insertion does not guarantee correct placement. It's important to verify the tube location through appropriate means like aspirating gastric contents. In the educational context, it is crucial for nurses to understand the importance of verifying tube placement using evidence-based methods to ensure the safety and well-being of the preterm baby. Proper tube placement is essential to prevent complications such as aspiration and ensure effective delivery of nutrition or medication. Nurses must follow established protocols and guidelines to confirm tube placement accurately.

Correct Answer: C

Rationale: In the immediate postpartum period, the priority nursing care goal for a client who had a vaginal delivery 2 hours earlier is to monitor and ensure a moderate lochial flow (Option C). Lochia is the vaginal discharge after childbirth, and assessing its amount, color, and odor is crucial in detecting signs of excessive bleeding or infection, which are common postpartum complications. Monitoring for a moderate flow indicates that the uterus is contracting well and decreasing the risk of hemorrhage, a critical concern in the early postpartum period. Option A, breastfeeding every 2 hours, is important for bonding and infant nutrition but is not the highest priority within the first few hours after delivery. Option B, consuming a nutritious diet, is important for recovery but is not as immediate a concern as monitoring for postpartum complications. Option D, ambulation, is beneficial for preventing complications such as deep vein thrombosis but is not as critical as ensuring proper uterine contraction and assessing for excessive bleeding. Educationally, this question highlights the importance of prioritizing nursing care goals based on the immediate needs of postpartum clients to ensure optimal outcomes and prevent complications in the early postpartum period. Understanding the significance of monitoring lochial flow can help students and healthcare providers provide safe and effective care to postpartum clients.

Correct Answer: C

Rationale: In this scenario, the correct nursing diagnosis is "C) Risk for fetal injury." This choice is appropriate because uncontrolled maternal diabetes poses significant risks to the developing fetus. High glucose levels in the mother can lead to fetal macrosomia (large birth weight), congenital anomalies, hypoglycemia at birth, and other complications that can harm the fetus during pregnancy and delivery. Option A, "Altered maternal skin integrity," is not the most appropriate diagnosis in this case as the primary concern is the potential harm to the fetus due to uncontrolled maternal diabetes, rather than skin integrity issues in the mother. Option B, "Deficient maternal fluid volume," is not the most suitable diagnosis at this time as the information provided does not suggest any immediate concerns related to maternal fluid volume that would outweigh the risk to the fetus posed by uncontrolled diabetes. Option D, "Fetal urinary retention," is not the correct diagnosis based on the information provided. While diabetes can lead to complications affecting the fetus, urinary retention specifically is not a common issue associated with uncontrolled diabetes during pregnancy. Educationally, understanding the importance of monitoring and managing diabetes in pregnancy is crucial for nurses caring for pregnant women with diabetes. Recognizing the potential risks to both the mother and the fetus allows for timely interventions and preventive measures to optimize outcomes for both. It highlights the need for close monitoring, patient education, and interprofessional collaboration to ensure the best possible care for pregnant women with diabetes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Late decelerations. Smoking 2 packs of cigarettes daily during pregnancy can lead to decreased oxygen supply to the fetus due to the vasoconstrictive effects of nicotine, which can result in fetal hypoxia. Late decelerations on the fetal heart rate monitor indicate uteroplacental insufficiency, a condition where the placenta is not providing enough oxygen to the fetus during contractions. This is a critical sign that immediate intervention may be needed to prevent fetal distress. Option A) Delayed placental separation is not directly related to smoking and is more commonly associated with conditions like placental abruption or uterine atony postpartum. Option C) Shoulder dystocia is usually related to maternal diabetes, fetal macrosomia, or pelvic abnormalities, and smoking does not directly increase the risk of this complication. Option D) Precipitous fetal descent is a rapid descent of the fetus through the birth canal, which is not specifically linked to smoking during pregnancy. Educationally, understanding the effects of maternal smoking on pregnancy outcomes is crucial for healthcare providers to provide optimal care and interventions to ensure the well-being of both the mother and the baby. Monitoring for signs of fetal distress, such as late decelerations in this case, is vital in managing high-risk pregnancies effectively.

Correct Answer: A

Rationale: In the scenario of the umbilical cord being clamped by the obstetrician, the correct physiological change taking place is that the baby's blood bypasses its pulmonary system. This process is known as the closure of the fetal shunts. The fetal circulation system includes shunts such as the ductus arteriosus and the foramen ovale, which allow blood to bypass the lungs since oxygenation occurs through the placenta during fetal development. When the cord is clamped, the baby transitions to breathing air and the pulmonary circulation becomes the primary route for blood flow, leading to the closure of these shunts. Option B, stating that the baby's oxygen level begins to drop, is incorrect because clamping the cord does not directly cause a drop in oxygen levels; rather, it initiates the transition to pulmonary respiration, ensuring proper oxygenation. Option C, mentioning bacteria invading the baby's bowel, is incorrect as clamping the cord does not trigger bacterial invasion. This process is more related to postnatal factors and not immediate cord clamping. Option D, referring to bilirubin rising in the baby's bloodstream, is also incorrect as cord clamping does not have a direct impact on bilirubin levels. Bilirubin elevation is typically associated with conditions like jaundice and is not influenced by the clamping of the umbilical cord. Understanding these physiological changes during birth is crucial for healthcare providers to ensure the safe transition of the newborn to extrauterine life. It is essential to know the timing and effects of cord clamping to support the baby's adaptation to breathing independently and the circulatory changes that occur during this critical period.