The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?
a. Bloody
b. Clear with bits of vernix caseosa
c. Green and thick
d. Yellow and cloudy with foul odor
ANS: B
Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium. Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.
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A client is pregnant with her first child. During her pregnancy she was diagnosed with gestational diabetes. She asks the nurse, "What are my chances of becoming a real diabetic later in life?" The best reply by the nurse would be,
a. "Normal physical changes of pregnancy have caused this to develop. It will disappear after delivery." b. "This condition lasts for the duration of the pregnancy. You will not develop diabetes later in life." c. "Women who demonstrate signs of diabetes during pregnancy always develop a mild form of the disease later in life." d. "Women diagnosed with gestational diabetes have an increased risk of developing diabetes later in life."
The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?
a. Keep the tube clamped. b. Suction the tube as needed. c. Leave the tube open to gravity drainage. d. Lower the tube to a point below the level of the stomach.
A patient being treated at the mental health center says, "I am having thoughts about suicide." Select the nurse's most therapeutic response
a. "Thank you for telling me, but there's nothing to worry about. We will handle it together." b. "Telling me about these feelings is a very positive action on your part." c. "It's important for you to be hospitalized as soon as possible." d. "Let's talk about the things you have to live for."
The mother of a breastfed newborn tells the nurse that the baby's stool is golden yellow, is pasty instead of firm, and has a sour milk odor. The best response on the part of the nurse would be which of the following?
a. "You probably need to feed this baby some cereal to firm up the stool." b. "Cut back on your fluid intake and be careful what you eat, as you pass this on to the baby." c. "I need to check your temperature and your breasts to determine if you have a breast abscess." d. "This is a normal stool for a newborn that is breastfed. Do not change anything about your breastfeeding."