Choice A rationale:

Placing the client in a semi-Fowler's position for 1 hour after administering the dinoprostone insert is not necessary. There is no evidence or indication that this position enhances the medication's effectiveness or safety.

Choice B rationale:

Instructing the client to avoid urinary elimination until after administration is not appropriate and can lead to discomfort and potential complications. There is no connection between urinary elimination and the administration of dinoprostone.

Choice C rationale:

Verifying that informed consent is obtained before administering any medication or procedure is a crucial nursing responsibility. Informed consent ensures that the client is fully aware of the risks, benefits, and alternatives, and gives permission for the procedure to take place.

Choice D rationale:

Allowing the medication to reach room temperature prior to administration is not necessary for a dinoprostone insert. Medications that require temperature adjustment are specified in the manufacturer's instructions or facility protocols, and this is not one of them.

Dinoprostone is a medication that is used to soften and dilate the cervix in pregnant women who need to have labor induced. It is inserted into the vagina as a gel, jelly, or a small tampon-like device.

According to the guidelines from the American College of Obstetricians and Gynecologists (ACOG), the correct answer is c. Verify that informed consent is obtained prior to administration4. This is because dinoprostone is associated with some risks and side effects, such as excessive bleeding, infection, uterine rupture, and fetal distress. Therefore, the provider should explain the benefits and risks of the medication to the client and obtain their written consent before proceeding with the induction.

The other options are incorrect for the following reasons:

a. Place the client in a semi-Fowler’s position for 1 hr after administration. This is not necessary, as the client can change positions as desired after the insertion of dinoprostone, unless there are other medical reasons to restrict their mobility.
b. Instruct the client to avoid urinary elimination until after administration. This is not advisable, as the client should be encouraged to empty their bladder before and after the insertion of dinoprostone, to reduce the risk of urinary tract infection and discomfort.
d. Allow the medication to reach room temperature prior to administration. This is not required, as dinoprostone can be administered at refrigerated or room temperature, depending on the product used

Choice A rationale:

A blood pressure reading of 80/50 mm Hg in a full-term newborn is considered low and should be reported to the provider. Normal blood pressure for a newborn is typically around 60-90 mm Hg systolic and 30-60 mm Hg diastolic.

Choice B rationale:

A respiratory rate of 55/min in a full-term newborn is within the normal range. The normal respiratory rate for newborns is typically 30-60 breaths per minute.

Choice C rationale:

A heart rate of 72/min in a full-term newborn is within the normal range. The normal heart rate for newborns is typically 70-190 beats per minute.

Choice D rationale:

A temperature of 36.5°C (97.7°F) in a full-term newborn is within the normal range. Normal axillary temperature for a newborn is generally considered to be between 36.5°C to 37.5°C (97.7°F to 99.5°F).

Choice A rationale:

Instructing the client to maintain scheduled mealtimes is essential for a postpartum client with type 1 diabetes mellitus who is breastfeeding. Consistent and balanced meals help stabilize blood glucose levels, especially in diabetic clients who need to manage their insulin.

Choice B rationale:

Checking blood glucose levels every 8 hours is not appropriate for a postpartum client with type 1 diabetes mellitus. Diabetic clients typically need to monitor their blood glucose more frequently, especially after meals and during breastfeeding.

Choice C rationale:

Instructing the client to take more insulin with each meal than she did prior to pregnancy is not accurate advice. The insulin requirements may change during pregnancy, but it is essential to follow the healthcare provider's guidance on adjusting insulin doses after delivery.

Choice D rationale:

Limiting carbohydrate intake to 30 grams per day is not suitable for a breastfeeding postpartum client with type 1 diabetes mellitus. Carbohydrates are a crucial source of energy, and breastfeeding mothers usually require more carbohydrates to support lactation and energy needs. Restricting carbohydrates to such a low level could be harmful.

Choice A rationale:

Oatmeal is a good source of fibre, but its fibre content per cup is not as high as some other options.

Choice B rationale:

Cabbage is a healthy choice with some fibre content, but it does not have as much fibre per cup as lentils.

Choice C rationale:

Lentils have the highest fibre content per cup compared to the other options listed. They are rich in both soluble and insoluble fibre, which helps promote bowel regularity and alleviate constipation.

Choice D rationale:

Asparagus is a nutritious vegetable but does not have as much fibre per cup as lentils.

Choice A rationale:

Vibroacoustic stimulation is an appropriate action to perform during a nonstress test if there are no fetal heart rate accelerations. It involves using sound or vibration to stimulate the fetus, potentially eliciting the desired heart rate accelerations.

Choice B rationale:

Placing the client in the Trendelenburg position is not indicated in this situation. It may not benefit the fetus and is not a standard intervention for nonreactive nonstress test results.

Choice C rationale:

Conducting a vaginal exam is not relevant to the situation described in the question. A nonreactive nonstress test does not require a vaginal exam.

Choice D rationale:

Collecting a specimen for an indirect Coombs test is not necessary for this scenario. The test result would not provide information relevant to the nonreactive nonstress test.

Choice A rationale:

Allowing parents to enter the nursery while wearing masks may be a preventive measure for some situations, but it is not a standard infection control procedure in a newborn nursery.

Choice B rationale:

Airborne precautions are not required for routine infection control in a newborn nursery. They are typically reserved for specific airborne-transmitted infections.

Choice C rationale:

Placing the newborn's foot on a sterile field during a heel stick is a procedure to maintain sterile technique but is not a general infection control instruction for the nursery.

Choice D rationale:

Placing newborn bassinets at least 3 feet apart is a crucial infection control measure in a newborn nursery. It helps prevent cross-contamination and the spread of infections among newborns. Proper spacing allows for better airflow and reduces the risk of contact transmission between infants.

Listeriosis is a foodborne illness that can have severe consequences during pregnancy. To minimize the risk of listeriosis, a pregnant client should avoid certain foods that are more likely to be contaminated with the bacteria Listeria. The correct statement that indicates an understanding of the teaching is:

C) "I can eat grilled chicken on a bun at lunchtime."

Grilled chicken is a safe option, and as long as it's properly cooked, it's a suitable choice during pregnancy. The other options are not recommended during pregnancy:

A) Soft cheeses, like Brie or feta, can carry a risk of Listeria contamination, so they should be avoided.

B) Seafood salad from the grocery store may not be safe as it could contain seafood that's been sitting at improper temperatures, which can increase the risk of foodborne illness.

D) Hot dogs can also be a risk as they are often not served steaming hot, which is necessary to kill any potential Listeria contamination.

Choice A rationale:

The Moro reflex, also known as the startle reflex, is elicited by making a loud noise above the newborn, causing them to extend their arms and legs and then bringing them back to the body in a hugging motion. This reflex is a normal developmental response in term newborns.

Choice B rationale:
Touching the newborn's cheek with a finger elicits the rooting reflex, where the newborn turns their head toward the stimulus, searching for a nipple or object to suck. It is a different reflex and not the Moro reflex.

Choice C rationale:
Tapping the newborn's forehead with a finger does not elicit any specific reflex. This action is not related to the Moro reflex.

Choice D rationale:
Turning the newborn's head to one side elicits the asymmetric tonic neck reflex (ATNR), not the Moro reflex. In ATNR, when the head is turned to one side, the arm on that side extends while the opposite arm flexes.

Choice A rationale:

A postpartum temperature of 37.4°C (99.3°F) is within the normal range. Mild temperature elevations can be expected in the immediate postpartum period without indicating infection.

Choice B rationale:

Uterine tenderness is a common finding in endometritis, which is an inflammation or infection of the inner lining of the uterus. The condition can cause pelvic pain and uterine tenderness.

Choice C rationale:

A white blood cell (WBC) count of 9,000/mm³ falls within the normal range for a postpartum client. In endometritis, an elevated WBC count would be expected due to the infection.

Choice D rationale:

Scant lochia (minimal vaginal discharge after childbirth) is a normal finding in the postpartum period and is not associated with endometritis. In endometritis, the lochia may be increased and foul-smelling.

The correct answer is c. Cleanse the newborn immediately after delivery. This is because cleansing the newborn can reduce the risk of HIV transmission through exposure to maternal blood or fluids. The other options are not appropriate for the following reasons:

a. Administer IV antibiotics to the newborn. This is not necessary unless the newborn has signs of infection or sepsis. Antibiotics do not prevent or treat HIV infection.
b. Encourage the mother to breastfeed her newborn. This is contraindicated for mothers with HIV, as breastfeeding can transmit the virus to the infant. Mothers with HIV should avoid breastfeeding and use formula or donor milk instead.
d. Initiate contact precautions for the newborn. This is not required for newborns exposed to HIV, as HIV is not transmitted by casual contact. Standard precautions are sufficient to prevent the spread of HIV and other bloodborne pathogens.