Which finding in a 36-week pregnant client is most concerning?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Proteinuria of +2 is the most concerning finding in a 36-week pregnant client. Proteinuria is the presence of abnormal levels of protein in the urine, which can indicate underlying issues like preeclampsia, a serious condition characterized by high blood pressure and organ damage. In a pregnant woman, particularly at 36 weeks, proteinuria can be a sign of preeclampsia, which requires immediate medical attention to prevent complications for both the mother and the baby. Now, let's discuss why the other options are not as concerning: A) Braxton Hicks contractions are common and considered normal in pregnancy, especially in the third trimester. They are usually irregular, mild, and do not indicate labor. B) Frequent urination is a common symptom in pregnancy due to hormonal changes and the growing uterus putting pressure on the bladder. While it can be uncomfortable, it is not typically a cause for concern. D) Weight gain of 2 pounds in a week is within the normal range for pregnancy, especially towards the end of the third trimester when the baby is growing rapidly. Sudden excessive weight gain or swelling, however, could be a sign of preeclampsia and should be monitored. Educationally, this question highlights the importance of recognizing concerning signs and symptoms in pregnant clients, especially those that could indicate severe conditions like preeclampsia. Understanding the significance of proteinuria in this context is crucial for nurses and healthcare providers to provide timely and appropriate care to ensure the well-being of both the pregnant individual and the unborn child.

Correct Answer: A

Rationale: In the context of a newborn receiving phototherapy for jaundice, the most important teaching for the mother is Option A) Ensure the newborn wears protective eyewear. Phototherapy involves exposing the baby's skin to light to help break down excess bilirubin. Without eye protection, the baby's eyes can be harmed by the bright lights used in phototherapy. Therefore, ensuring that the newborn wears protective eyewear is crucial to prevent eye damage. Option B) Increase the newborn's fluid intake is not the most important teaching in this scenario. While adequate hydration is important for newborns, it is not directly related to the safety and effectiveness of phototherapy. Option C) Turn the newborn frequently to prevent pressure sores is not the priority teaching here. While repositioning is essential for preventing pressure sores in hospitalized patients, it is not the primary concern for a newborn undergoing phototherapy. Option D) Monitor bilirubin levels every 8 hours is important for healthcare providers to do, but it is not a teaching that would directly involve the mother of the newborn. Teaching the mother about the importance of protective eyewear during phototherapy is more relevant and crucial for her active participation in the care of her newborn. In an educational context, this question highlights the importance of patient safety and family education in newborn care, emphasizing the specific considerations involved in managing newborns undergoing phototherapy for jaundice. It underscores the significance of providing clear and concise instructions to parents to ensure the well-being of their newborns during medical interventions.

Correct Answer: D

Rationale: Using clean technique for all procedures helps prevent infection in the labor and birth area. A clean technique involves maintaining cleanliness and limiting contamination during procedures. This includes proper hand hygiene, use of clean gloves, and ensuring that equipment and supplies are kept clean and sterile as needed. By adhering to clean techniques, the nurse reduces the risk of introducing harmful microorganisms into the labor and birth area, ultimately reducing the chances of infection for both the mother and baby. It is important for the nurse to practice proper infection control measures to provide a safe environment for labor and birth.

Correct Answer: A

Rationale: Mongolian spots are a common benign skin condition in newborn babies, especially those with darker skin tones, such as African American babies. These spots appear as blue or purple bruises or patches, typically on the lower back and buttocks, and can easily be mistaken for bruises caused by physical harm. It is important for healthcare providers and caregivers to be aware of Mongolian spots to avoid confusion with signs of abuse. In this case, the nurse is likely explaining that the bruises on the newborn girl's buttocks are due to Mongolian spots, not being spanked.

Correct Answer: A

Rationale: Before performing an amniotomy (artificial rupture of membranes), it is essential to assess the fetal presentation, position, and station. This assessment helps ensure that the procedure is performed safely without causing harm to the baby. Knowing the fetal presentation (such as breech, transverse, or vertex), position (occiput anterior, occiput posterior, etc.), and station (how far down the baby's head is in the pelvis) allows the obstetrician to determine the best approach and technique for the amniotomy. It also helps in reducing the risk of complications during labor induction and delivery. Therefore, this assessment is crucial in ensuring the well-being of both the mother and the baby during the labor process.