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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. - 🧠
ANSWER ✔✔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 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) - 🧠 ANSWER ✔✔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
assessed every 15 to 20 minutes during labor but is not specific for AROM.
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, 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 - 🧠 ANSWER ✔✔B. Skin color
that is slightly jaundiced