A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take?

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Maternal Newborn Nclex Practice Questions Questions

Question 1 of 5

A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take?

Correct Answer: B

Rationale: Late decelerations of the fetal heart rate can indicate uteroplacental insufficiency, which may be a result of decreased oxygen supply to the fetus. Placing the client in a lateral position can help enhance uteroplacental perfusion by relieving pressure on the vena cava and improving maternal blood flow to the placenta. This position change can help improve fetal oxygenation and decrease the occurrence of late decelerations. Other actions such as administering oxygen and assessing for other contributing factors should also be done, but placing the client in a lateral position is the most appropriate immediate intervention in this scenario.

Question 2 of 5

A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: Ensuring the newborn's mouth is wide open before latching to the breast is the correct action to take when caring for a client experiencing sore nipples from breastfeeding. When the newborn latches onto the breast correctly with a wide open mouth, it helps to prevent nipple soreness and discomfort by allowing proper positioning and attachment, which reduces pressure on the nipple. This action can promote effective and comfortable breastfeeding for both the client and the newborn. Placing a snug dressing on the nipple when not breastfeeding (Choice A) could hinder air circulation, leading to moisture, which may increase the risk of nipple soreness. Limiting the newborn's feeding to 10 minutes on each breast (Choice C) can be insufficient for adequate milk intake and can lead to feeding issues. Instructing the client to begin the feeding with the nipple that is most tender (Choice D) may exacerbate the issue and cause further discomfort.

Question 3 of 5

A nurse is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?

Correct Answer: B

Rationale: Neonatal opioid withdrawal syndrome, also known as neonatal abstinence syndrome (NAS), can occur in newborns who were exposed to opioids in utero. Symptoms of NAS can include tremors, irritability, high-pitched crying, poor feeding, vomiting, diarrhea, sweating, and sneezing. The severity of symptoms can vary depending on the type of opioid exposure, dosage, and duration of exposure. In this case, the nurse should expect to see moderate tremors of the extremities in the newborn experiencing opioid withdrawals at 48 hours old. It is important for the nurse to monitor and manage the newborn's withdrawal symptoms closely to ensure their safety and well-being.

Question 4 of 5

Which environment can assist a pregnant teen to achieve the task of establishing a stable identity?

Correct Answer: C

Rationale: A school-based mothers' program can assist a pregnant teen in establishing a stable identity by providing specialized support and resources tailored to their unique needs. These programs typically offer academic assistance, childcare services, counseling, and parenting classes. By being in a supportive and understanding environment with other young mothers, the pregnant teen can feel accepted and supported, which can help boost her self-esteem and confidence. Additionally, these programs often focus on empowering young mothers to continue their education and set goals for their future, contributing to the development of a stable identity.

Question 5 of 5

A nurse is doing genetic counseling with a couple. give to a client undergoing a mastectomy? The mother has Down syndrome and the father

Correct Answer: D

Rationale: When a woman with Down syndrome (trisomy 21) has a child with a man who does not have any chromosomal abnormalities, the chance of their offspring having Down syndrome is 25%. This is because the mother can only pass on one copy of the extra chromosome 21 to her child, resulting in a 50% chance of passing it on. However, since the father does not have an extra chromosome 21 to contribute, the overall chance of the child having Down syndrome is reduced to 25%.

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