During the initial assessment of a newborn, the nurse observes that the umbilical cord contains two arteries and one vein. Which nursing action is most appropriate?

Notify the healthcare provider, as this finding may be associated with congenital anomalies.

Document the finding as normal and continue with routine newborn care.

Apply warm compresses to the cord to promote circulation.

Document the finding as abnormal and continue with routine newborn care.

Answer and Explanation

The Correct Answer is B

A. Notify the healthcare provider, as this finding may be associated with congenital anomalies: Two arteries and one vein represent the normal anatomy of the umbilical cord. Notification is unnecessary unless only one artery (a single umbilical artery) is present, which could indicate possible congenital anomalies.

B. Document the finding as normal and continue with routine newborn care: The normal umbilical cord structure consists of two arteries that carry deoxygenated blood from the fetus and one vein that returns oxygenated blood to the fetus. This finding confirms a normal cord and requires no additional interventions beyond standard care.

C. Apply warm compresses to the cord to promote circulation: The umbilical cord no longer functions in circulation after birth. Applying warm compresses would serve no purpose and could introduce unnecessary risk of infection or injury to the cord stump.

D. Document the finding as abnormal and continue with routine newborn care: Labeling a normal finding as abnormal could lead to confusion in medical records and unnecessary evaluations. Proper documentation should accurately reflect the expected normal anatomy of two arteries and one vein.

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Correct Answer is C

Explanation

A. Lordosis refers to a straightening of the spine to accommodate fetal weight, which reduces flexibility and causes back pain: Lordosis is an increased inward curvature of the lumbar spine, not a straightening. The curvature helps maintain balance rather than reducing flexibility.

B. Lordosis is caused by compression of spinal nerves from the expanding uterus and is typically a sign of neurologic compromise: Lordosis is a normal musculoskeletal adaptation during pregnancy, not a sign of nerve compression or neurologic compromise.

C. Increased lumbar lordosis is a compensatory change in spinal curvature that shifts the center of gravity forward to balance the enlarging uterus: The forward shift in center of gravity increases strain on lumbar muscles and ligaments, contributing to common pregnancy-related lower back pain.

D. Lordosis develops due to increased thoracic spine curvature and leads to shoulder pain in late pregnancy: Lordosis involves the lumbar spine, not the thoracic spine, and is associated with lower back pain, not shoulder pain.

A. 4-2-5-6-1-3 B. 2-5-4-6-3-1 C. 5-2-4-6-1-3 D. 2-4-5-6-1-3

Correct Answer is D

Explanation

A. 4-2-5-6-1-3: This sequence places descent before engagement and flexion after engagement, which does not follow the typical progression of fetal movements during labor. Engagement usually occurs before descent.

B. 2-5-4-6-3-1: This order incorrectly places flexion before descent and extension after internal rotation, which does not align with the physiological process of vaginal birth. The fetus must descend before extension occurs.

C. 5-2-4-6-1-3: Starting with flexion before engagement is incorrect because engagement of the presenting part into the pelvis occurs prior to the fetus flexing its head. This disrupts the normal sequence of cardinal movements.

D. 2-4-5-6-1-3: Engagement occurs first as the fetal presenting part enters the pelvic inlet, followed by descent through the birth canal. Flexion of the fetal head allows passage through the pelvis, internal rotation aligns the head with the maternal pelvis, extension occurs as the head crowns, and external rotation completes the birth of the shoulders.

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During the initial assessment of a newborn, the nurse observes that the umbilical cord contains two arteries and one vein. Which nursing action is most appropriate?

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Naxlex Comprehensive Predictor Exams

A pregnant client in her third trimester complains of lower back pain. The nurse explains that this discomfort is common due to postural changes. Which of the following best explains the role of lordosis in pregnancy-related back pain?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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