The nurse knows that the occurrence of shoulder dystocia during labor is most likely related to which of the following?

Advance maternal age

Polyhydramnios

Macrosomia

Preterm birth

Answer and Explanation

The Correct Answer is C

A. Advanced maternal age may increase the risk of certain pregnancy complications, but it is not specifically associated with shoulder dystocia. Other factors, such as fetal size, are more directly related to shoulder dystocia.

B. Polyhydramnios (excess amniotic fluid) can sometimes be associated with complications during labor, but it is not the primary risk factor for shoulder dystocia. The condition most often involves difficulties with the fetal position or size rather than the amount of fluid.

C. Macrosomia (a large baby, typically defined as a birth weight over 8 pounds 13 ounces or 4000g) is the primary risk factor for shoulder dystocia. Shoulder dystocia occurs when the baby’s shoulders become stuck during delivery, often due to the larger size of the baby. The baby’s shoulders may be too broad to pass through the birth canal easily, which increases the likelihood of this complication.

D. Preterm birth is not a significant risk factor for shoulder dystocia. Preterm babies are typically smaller and less likely to encounter the same birth canal obstruction issues associated with shoulder dystocia.

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Correct Answer is A

Explanation

A. The client talks frequently about her labor and delivery is a characteristic behavior of the Taking In phase, which occurs during the first few days postpartum. During this phase, the mother is primarily focused on her own needs and recovering from childbirth. She may want to discuss her labor and delivery experience and may be more focused on rest and reflection rather than engaging with the baby.

B. The client hesitates to initiate contact with the baby is more characteristic of the Taking Hold phase, which comes after the Taking In phase. In the Taking Hold phase, the mother begins to take more responsibility for her baby’s care, though she may still seek guidance.

C. The client questions the nurse about the amount of formula for the baby indicates a more active engagement in learning about infant care, which is typical of the Taking Hold phase, where the mother starts to focus on baby care and becomes more involved.

D. The client requests between meals snacks is a sign of physical recovery and possibly an increased need for nourishment, but it does not specifically indicate being in the Taking In phase. This behavior may occur in any phase but is not a defining characteristic.

A. "It is possible that your baby experienced birth trauma that has caused some bleeding" B. "Your baby has an infection that will need to be evaluated by the physicians C. "Breastfed babies often experience this type of bleeding problem due to lack of Vitamin K in the mother's milk" D. "Some female infants experience menstruation like symptoms as a result of the mother's hormones

Correct Answer is D

Explanation

A. "It is possible that your baby experienced birth trauma that has caused some bleeding." While birth trauma can cause bleeding, it is not the most common cause of a small blood-tinged area in a newborn's diaper, particularly in female infants. Trauma-related bleeding would typically be more noticeable or involve more significant injury.

B. "Your baby has an infection that will need to be evaluated by the physician." This statement is unlikely, as the presence of a small amount of blood-tinged discharge in a newborn’s diaper is not typically a sign of infection. Infection would present with other symptoms, such as fever, irritability, or abnormal discharge.

C. "Breastfed babies often experience this type of bleeding problem due to lack of Vitamin K in the mother's milk." This is incorrect. Newborns are given a Vitamin K injection shortly after birth to prevent bleeding issues (such as Vitamin K deficiency bleeding). Lack of Vitamin K in the mother's milk is not a cause of blood-tinged discharge in female infants.

D. "Some female infants experience menstruation-like symptoms as a result of the mother's hormones." This is the correct response. A small amount of blood-tinged vaginal discharge (often described as pseudomenstruation) in female newborns is common and occurs due to the influence of the mother's hormones (mainly estrogen) passed to the baby in utero. It typically resolves within a few days to weeks and is considered a normal physiological response.

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The nurse knows that the occurrence of shoulder dystocia during labor is most likely related to which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care to a postpartum woman. Which of the following behavior by the client would indicate the client is in the Taking in phase?

Correct Answer is A

Explanation

The new mother asks the nurse about the presence of a small blood-tinged area on her daughter's diaper. Which response by the nurse would be most accurate?

Correct Answer is D

Explanation

The nurse is caring for a client, which symptom indicates severity of pregnancy- induced hypertension and signs of HELLP syndrome?

A woman is receiving magnesium sulfate as part of her treatment for severe preeclampsia. The nurse is monitoring the woman's serum magnesium levels. The nurse determines that the drug is at a therapeutic level based on which result?

A client with severe preeclampsia is receiving magnesium sulfate as part of the treatment plan. To ensure the client's safety, which compound would the nurse have readily available?

A woman with placenta previa is being treated with expectant management. The woman and fetus are stable. The nurse is assessing the woman for possible discharge home. Which statement by the woman would suggest to the nurse that home care might be inappropriate?

The nurse is performing an Apgar score on a newborn at 5 minutes after birth. The infant has a heart rate of 100, pink body and blue hands, active motion, and a strong lust cry and respirations. What is the Apgar score that should be assigned to this infant?

A nurse is conducting an assessment of a woman who has experienced PROM. Which amniotic fluid finding would lead the nurse to suspect infection as the cause of a client's PROM?

The nurse dries the neonate thoroughly and promptly changes wet linens. The nurse does so to minimize heat loss via which mechanism?