min. Provider was notified of the client's status and assessment, and new orders were received.

Medical History: The client has a history of three previous pregnancies (Gravida 4 Para 3).Querry: The nurse is contacting the primary health care provider regarding the client's status.

Which of the following interventions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

Give betamethasone 12 mg IM now and repeat in 24 hr.

Begin loading dose of magnesium sulfate 9 g over 30 min.

Position the client in a lateral position.

Administer terbutaline 0.25 mg subcutaneous stat.

E. Prepare for an emergency cesarean birth

Question Solution

Correct Answer : A,B,C

Choice A: Give betamethasone 12 mg IM now and repeat in 24 hr.

Rationale: Betamethasone is administered to accelerate fetal lung maturity in cases of preterm labor. Given the client's gestational age of 31 weeks, this intervention is appropriate to help reduce the risk of respiratory distress syndrome in the newborn.

Choice B: Begin loading dose of magnesium sulfate 9 g over 30 min.

Rationale: Magnesium sulfate is used for neuroprotection of the fetus in preterm labor to reduce the risk of cerebral palsy. The loading dose is typically given to achieve therapeutic levels quickly.

Choice C: Position the client in a lateral position.

Rationale: Positioning the client in a lateral position helps improve uteroplacental blood flow and can reduce the intensity of contractions, which is beneficial in managing preterm labor.

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A. Turn the newborn's head quickly to one side. B. Perform a sharp hand clap near the infant. C. Stroke the outer edge of the sole of the foot from near the heel up toward the toes. D. Place a finger at the base of the newborn's toes.

Correct Answer is B

Explanation

Choice A rationale

Turning the newborn's head quickly to one side elicits the tonic neck reflex, not the Moro reflex. The tonic neck reflex involves the newborn's arm extending on the side where the

head is turned and the opposite arm bending at the elbow, resembling a fencing position.

Choice B rationale

Performing a sharp hand clap near the infant elicits the Moro (startle) reflex, which is characterized by the infant throwing their arms outward, opening their hands, and then bringing

the arms back in. This is a response to sudden stimuli and is a normal reflex in newborns.

Choice C rationale

Stroking the outer edge of the sole of the foot from near the heel up toward the toes elicits the Babinski reflex, not the Moro reflex. The Babinski reflex is characterized by the big toe

moving upward or toward the top surface of the foot and the other toes fanning out.

Choice D rationale

Placing a finger at the base of the newborn's toes elicits the plantar grasp reflex, not the Moro reflex. The plantar grasp reflex involves the toes curling around the finger or object

placed at the base of the toes. .

A. Breast tenderness. B. Fetal heart tones detected by ultrasound. C. Fetal movement. D. Positive urine pregnancy test. E. Positive urine pregnancy test.

Correct Answer is D

Explanation

Choice A rationale

Breast tenderness is considered a presumptive sign of pregnancy, as it can result from hormonal changes, but it is not definitive enough to confirm pregnancy.

Choice B rationale

Fetal heart tones detected by ultrasound are a positive sign of pregnancy. However, it is not a probable sign as it is definitive evidence of an existing pregnancy.

Choice C rationale

Fetal movement, often felt later in pregnancy, is a positive sign. It indicates an existing pregnancy but is not used to initially diagnose pregnancy.

Choice D rationale

A positive urine pregnancy test is a probable sign of pregnancy. It detects the presence of hCG (human chorionic gonadotropin), a hormone produced during pregnancy, and is a widely used indicator of probable pregnancy. .

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Correct Answer is B

Explanation

Correct Answer is D

Explanation

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A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro (or startle) reflex, the nurse should take which of the following actions?

Correct Answer is B

Explanation

A client suspects she is pregnant. The nurse is discussing the probable signs of pregnancy with the client. Which of the following findings should the nurse include?

Correct Answer is D

Explanation

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

A nurse is receiving a report on a new postpartum admission. Her medical history includes chronic hypertension. The client is asking about postpartum orders. Which of the following would be contraindicated based on the client's medical history?

A nurse is caring for a newborn with hyperbilirubinemia and is being treated with phototherapy. For each of the following nursing actions, specify if it is indicated or contraindicated with phototherapy treatment.

A nurse is caring for a client in labor at 39 weeks of gestation. Which of the following assessment findings requires follow-up?

A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

A nurse in a prenatal clinic is caring for a client who is pregnant and asks the nurse for her estimated date of birth (EDB). The client's last menstrual period began on October 17. What is the client's EDB? (State the date in MMDD. For example, October 17 is 1017)

A nurse is caring for a newborn client. The assessment findings include a high-pitched cry, increased muscle tone, frequent yawning, poor feeding with projectile vomiting, and tachypnea. What condition does the nurse suspect?

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