During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?

Correct Answer: B

Rationale: The correct answer is option B: Palpate the fundus of the uterus. This technique helps the nurse identify the fetal lie by feeling for the position of the baby's head or buttocks at the top of the uterus. By palpating the fundus, the nurse can determine whether the baby is in a vertex (head down) or breech (head up) position. This method is effective in assessing the fetal lie as it provides direct information about the baby's orientation within the uterus. Option A is incorrect because applying palms to the sides of the uterus does not specifically help identify the fetal lie. Option C is incorrect as grasping the lower uterine segment does not provide information on the fetal lie. Option D is incorrect because standing facing the client's feet with fingertips outlining cephalic prominence is not a technique used to determine fetal lie.

Correct Answer: C

Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention. Incorrect choices: A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration. B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue. D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.

Correct Answer: B

Rationale: The correct answer is B: Position the client with one hip elevated. This is the priority action because the client's contractions are frequent and of significant duration, indicating active labor. Elevating one hip can help improve fetal oxygenation and blood flow during contractions. It can also help optimize fetal positioning for a smoother labor process. Choice A: Notifying the provider is important but not the priority at this moment. The nurse should first address immediate client needs. Choice C: Asking about pain medication is important, but managing the client's positioning for labor progress takes precedence. Choice D: Having the client void is a routine step in labor management but is not the priority action in this scenario.

Correct Answer: D

Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby. A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding. B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support. C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns. In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.

Correct Answer: D

Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment. A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth. B: Milia spots are small, white, raised bumps on the skin, not found in the mouth. C: Erythema toxicum is a common benign rash in newborns, not related to the mouth. In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.

Correct Answer: A

Rationale: The correct answer is A: Moderate lochia rubra. This indicates normal postpartum bleeding 2 days after delivery. Bright red lochia with small clots is expected at this stage. Excessive lochia serosa (B) and scant lochia serosa (D) are not appropriate as serosa typically appears after the first few days postpartum. Light lochia rubra (C) does not accurately describe the amount of bleeding observed in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Postpartum blues. This temporary condition occurs in the first few days after childbirth and is characterized by symptoms like tearfulness, insomnia, lack of appetite, and feeling letdown. Here's the rationale: 1. Postpartum blues are common and typically resolve within a few days to a week postpartum. 2. The symptoms mentioned align with the typical presentation of postpartum blues, which includes mood swings, irritability, and crying spells. 3. Postpartum fatigue (choice A) is a general symptom post-childbirth but does not specifically encompass the emotional and psychological symptoms described. 4. Postpartum psychosis (choice B) is a severe condition characterized by hallucinations, delusions, and disorganized thinking, which are not present in the client's presentation. 5. Letting-go phase (choice C) refers to the process of detachment from the pregnancy and accepting the reality of the newborn, but it does not encompass the specific symptoms described in

Correct Answer: B

Rationale: The correct answer is B: Your son is displaying an adverse sibling response. This is the correct answer because the 4-year-old's regression in toilet training is likely a response to the recent birth of a new sibling. This behavior is common as the older child may feel jealous or neglected, leading to regression. Providing this statement will help the client understand the underlying cause of the behavior and address it appropriately. Incorrect choices: A: This choice suggests the child was not ready for toilet training, which is not the primary issue here. C: Counseling may be beneficial in some cases but is not the first-line intervention for this situation. D: Enrolling in preschool may not directly address the underlying cause of the behavior, which is related to the new sibling.

Correct Answer: B

Rationale: The correct answer is B: Appropriate for gestational age. A newborn is considered appropriate for gestational age when their weight falls within the 10th to 90th percentiles for their gestational age. In this case, the newborn is in the 60th percentile for weight, indicating that the weight is appropriate for the gestational age of 38 weeks. Choice A: Low birth weight is incorrect because a newborn is classified as low birth weight when their weight is below 2,500 g regardless of gestational age. Choice C: Small for gestational age is incorrect because a newborn is classified as small for gestational age when their weight is below the 10th percentile for their gestational age. Choice D: Large for gestational age is incorrect because a newborn is classified as large for gestational age when their weight is above the 90th percentile for their gestational age.