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An expectant father tells the nurse he fears that his wife is
"losing her mind." He states that she is constantly rubbing
her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which
recommendation should the nurse make to this expectant
father?
A.Suggest that his wife seek professional counseling to deal
with her symptoms.
B.Explain that his wife is exhibiting ambivalence about the
pregnancy.
C. Ask him to report similar abnormal behaviors at the next
prenatal visit.
D.Reassure him that normal maternal-fetal bonding is
occurring. - Correct Answers ✅D) Reassure him that
normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding
and do not reflect ambivalence. No intervention is needed.
Quickening, the first perception of fetal movement, occurs at
17 to 20 weeks of gestation and begins a new phase of
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prenatal bonding during the second trimester. Options A and
C are not necessary because the behaviors displayed are
normal.
The nurse is preparing a laboring client for an amniotomy.
Immediately after the procedure is completed, it is most
important for the nurse to obtain which information?
A.Maternal blood pressure
B.Maternal temperature
C.Fetal heart rate (FHR)
D.White blood cell count (WBC) - Correct Answers ✅C.
Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure
to detect changes that may indicate the presence of cord
compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the
condition of the cervix is favorable. The fluid should be
assessed for color, odor, and consistency. Option A should be
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assessed every 15 to 20 minutes during labor but is not
specific for AROM. Option B is monitored hourly after the
membranes are ruptured to detect the development of
amnionitis. Option D should be determined for all clients in
labor.
A nurse receives a shift change report for a newborn who is
12 hours post-vaginal delivery. In developing a plan of care,
the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
D.Red patches on the cheeks and trunk - Correct Answers
✅B. Skin color that is slightly jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by
elevated levels of bilirubin, which should be further evaluated
in a newborn <24 hours old. Acrocyanosis (blue color of the
hands and feet) is a common finding in newborns; it occurs
because the capillary system is immature. Milia are small
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white papules present on the nose and chin that are caused
by sebaceous gland blockage and disappear in a few weeks.
Small red patches on the cheeks and trunk are called
erythema toxicum neonatorum, a common finding in
newborns.
A breastfeeding postpartum client is diagnosed with mastitis,
and antibiotic therapy is prescribed. Which instruction should
the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are
completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant
latching onto the infected breast.
C.Breastfeed on the unaffected breast only until the mastitis
subsides.
D.Dilute expressed breast milk with sterile water to reduce
the antibiotic effect on the infant. - Correct Answers
✅A.Breastfeed the infant, ensuring that both breasts are
completely emptied.