The labor and delivery nurse would make it a priority to assess which two newborn body systems
immediately after birth?
a. Gastrointestinal and hepatic
b. Urinary and hematologic
c. Neurologic and temperature control
...
The labor and delivery nurse would make it a priority to assess which two newborn body systems
immediately after birth?
a. Gastrointestinal and hepatic
b. Urinary and hematologic
c. Neurologic and temperature control
d. Respiratory and cardiovascular
Rationale: To begin life, the infant must make the adaptations to establish respirations and circulation. These
two changes are crucial to life. All other body systems become established over a longer period of time.
A primigravida client of 16 weeks' gestation states that she has not yet felt fetal
movement. What is the nurse's best response?
a. "Your fetus will move any day now. Call me in a week if you don't feel it."
b. "Your fetus will begin moving at about 20 weeks' gestation."
c. "You should have been feeling the movement already."
d. "Your fetus has been moving for the past 9 weeks without you feeling it. You will
feel it within a month."
Rationale: The embryo’s muscles spontaneously contract beginning at 7 weeks. The mother
perceives sensations of movement of the fetus from 16 to 20 weeks’ gestation. A primigravida
usually perceives movement closer to 20 weeks.
The client experienced an 18-hour labor with a second stage that lasted 2 hours. When the nurse brings
the infant into the room 1 hour after delivery, the client tells the nurse to leave the infant in the crib and
shows no interest in holding the newborn. The nurse should record which nursing diagnosis in the plan
of care?
a. Ineffective Individual Coping related to assuming parental role
b. Powerlessness related to loss of individual choices
c. Fatigue related to prolonged labor
d. Anxiety related to feelings of incompetence in parenting role
Rationale: Although this client is not demonstrating positive signs of bonding at this time, it is
important to look at her history before concluding that she is not bonding well with her infant.
This client just experienced a long labor and the influence of fatigue on the attachment process
should be considered. It is important to continue to assess infant bonding with this client
throughout her hospitalization to reach a nursing judgment based on evidence.
A client with a strong family tendency toward hypertension denies he will get high blood pressure
because he watches what he eats, gets plenty of exercise, and maintains a normal weight. When
implementing the plan of care, the nurse would do which of the following?
a. Praise the client and reassure him that these actions will prevent him from becoming hypertensive.
b. Emphasize that no matter what he does, the client will eventually develop hypertension because of his
family history.
c. Recognize the client's efforts towards a healthy lifestyle and emphasis that early detection is essential
to prevent complications.
d. Recommend that the client request antihypertensive medications prophylactically because of his
family history.
Rationale: Lifestyle modifications and recognition of risk factors are important parts of prevention of longterm complications. Encouraging the client to maintain his current lifestyle and follow up with health
screening would be the best plan of action
A mother brings a 3-year-old child to the clinic for a well-child checkup. The child has not
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