Question

A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Answer 1

Correct Answers:

Cluster the newborn's care activities

Rationale :

🍼Clustering care minimizes unnecessary handling and allows preterm infants to have longer periods of uninterrupted rest, which supports neurodevelopment.

🧠Preterm newborns are especially vulnerable to overstimulation due to their immature nervous systems, so grouping care reduces sensory overload.

🛏️Rest periods help with brain maturation, growth, and organization, which are essential during this critical developmental stage.

📋This approach mimics the womb environment by promoting consistent sleep–wake cycles, enhancing overall neurological outcomes.

📌Core Message

Clustering care helps reduce stress and overstimulation in preterm infants, supporting development and restful sleep cycles.

Answer 2

Correct Answers

Auscultation of fetal heart tones heard via Doppler [ Positive ]
Ultrasound verification of embryo or fetus [ Positive ]
Amenorrhea [ Presumptive ]
Fetal movement felt by experienced clinician [ Positive ]
Chadwick’s sign [ Probable ]
Positive HCG pregnancy test [ Probable ]
Fatigue, nausea and vomiting [ Presumptive ]
Breast tenderness [ Presumptive ]

Rationale :

🩸Presumptive signs are subjective symptoms reported by the patient such as fatigue, nausea, and amenorrhea, which suggest but don't confirm pregnancy.

🔍Probable signs are objective findings like positive pregnancy tests or Chadwick’s sign that indicate pregnancy but can have other causes.

🎧Positive signs are definitive and confirm pregnancy, like hearing fetal heart tones, visualizing the fetus on ultrasound, or feeling fetal movement.

📚Understanding these categories helps in accurate nursing assessment and patient education during early prenatal care.

📌Core Message

Pregnancy signs are categorized as presumptive (subjective), probable (objective), and positive (definitive)—with positive signs directly confirming fetal presence.

Answer 3

Correct Answers:

You'll need an extra 400 to 500 calories per day while breastfeeding.

Rationale :

🍼Lactation significantly increases a mother's caloric demands to support milk production and infant growth.

📈Most guidelines recommend an additional 400–500 calories/day during breastfeeding to maintain energy balance and prevent fatigue.

💪This extra intake ensures the mother can meet both her own nutritional needs and the newborn's through adequate milk supply.

📋The nurse should provide specific caloric guidance to prevent undereating or excessive dieting postpartum.

📌Core Message

Breastfeeding moms need 400–500 extra calories per day to support milk production and energy needs.

Answer 4

Correct Answers:

I used a diaphragm prior to this pregnancy and I plan to use my old one when we start having sex again.
I will be breastfeeding for the next 6 months. We will start using a condom after I have my first period.
I plan to have an intrauterine device (IUD) implanted in my arm. We will be using condoms until I get an IUD.

Rationale :

⚠️A diaphragm used before pregnancy must be refitted postpartum, as childbirth changes cervical and vaginal anatomy, increasing the risk of contraceptive failure.

🍼Breastfeeding alone is not a reliable contraceptive unless strict criteria for the lactational amenorrhea method (LAM) are met—ovulation can occur before the first period.

💉Confusing an intrauterine device (IUD) with an arm implant (like Nexplanon) reveals misunderstanding of contraceptive methods, needing correction.

📋The remaining statements reflect appropriate understanding of abstinence before postpartum clearance and correct vasectomy follow-up with semen analysis.

📌Core Message

Misuse or misunderstanding of contraception like using an old diaphragm, relying on breastfeeding, or confusing an IUD with an implant indicates a need for further teaching.

Answer 5

Correct Answers:

Massage the uterus firmly to maintain uterine contraction

Rationale :

🩸The greatest risk during the third stage of labor is postpartum hemorrhage due to uterine atony.

✋Firm uterine massage stimulates contraction of the uterus, compressing blood vessels and reducing bleeding.

💊This action helps prevent complications such as hypovolemic shock and excessive blood loss.

📋Nurses should initiate massage immediately after placenta delivery and monitor fundal firmness and location.

📌Core Message

In the third stage of labor, firm uterine massage is crucial to prevent postpartum hemorrhage from uterine atony.

Answer 6

Correct Answers:

Are unable to shiver effectively to increase heat production and lack subcutaneous fat to provide insulation

Rationale :

🧊Newborns, especially preterm, have immature thermoregulatory systems and cannot shiver to generate heat.

🧼They also lack adequate subcutaneous fat, which reduces heat retention and insulation.

🌡️They rely on non-shivering thermogenesis, primarily through brown fat metabolism, which is limited.

📋Nursing care must include external heat support and strategies to reduce heat loss (e.g., warm blankets, radiant warmers).

📌Core Message

Newborns can't shiver effectively and lack insulating fat, making them prone to heat loss and requiring external thermoregulation.

Answer 7

Correct Answers

The contractions subside with activity or rest [ False ]
The contractions become progressively stronger and occur together [ True ]
Uterine pains start in the lower back and radiate to the abdomen [ True ]
Cervical dilation and effacement occur [ True ]
Contractions are irregular and do not increase in intensity [ False ]
Contractions become stronger and more intense with walking and activity [ True ]

Rationale :

🔄False labor contractions often decrease with rest or hydration and are irregular in timing and strength.

🔁True labor features regular, intensifying contractions that often start in the lower back and radiate forward, and lead to cervical changes.

🚶‍♀️Unlike false labor, true labor contractions become stronger with activity, not weaker.

📋Distinguishing the two helps avoid unnecessary hospital visits and provides accurate labor education.

📌Core Message

True labor involves regular, strong contractions that lead to cervical dilation, while false labor is irregular and eases with rest or movement.

Answer 8

Correct Answers:

Contractions are irregular and do not increase in intensity

Rationale :

🔁False labor contractions are irregular, vary in intensity, and do not get stronger or closer together, unlike true labor.

🛌They often subside with rest, hydration, or position change, and do not cause cervical changes.

📉These contractions are more discomfort than functional, and usually do not signal the start of labor.

📋Recognizing these patterns allows clients to distinguish between false and true labor, preventing unnecessary hospital visits.

📌Core Message

False labor is best identified by irregular, non-intensifying contractions that go away with rest or activity changes.

Answer 9

Correct Answers

Blank 1 Correct Option: Promethazine (Phenergan)
Blank 2 Correct Option: Nalbuphine (Nubain)

Rationale :

🤢Promethazine is a commonly used antiemetic during labor that controls nausea and vomiting.

💉Nalbuphine is an opioid analgesic used for moderate to severe pain relief during labor without significant respiratory depression.

🧪These medications are labor-safe options, commonly administered to support comfort and symptom control.

📋Nurses must know the purpose and timing of supportive medications during labor to improve maternal experience.

📌Core Message

During labor, Promethazine treats nausea and Nalbuphine manages pain, making them common antiemetic and analgesic choices.

Answer 10

Correct Answers:

Softening of the cervix (Hegar's sign)
Ballottement
Positive pregnancy test

Rationale :

🔍Probable signs of pregnancy include objective findings like Hegar's sign (soft cervix), ballottement, and positive pregnancy tests.

🩺They suggest pregnancy but are not definitive, as some could result from other conditions.

🧠Auscultating fetal heart tones or seeing the fetus on ultrasound are positive signs, while amenorrhea is a presumptive sign.

📋Knowing the distinctions helps guide accurate diagnosis and prenatal education.

📌Core Message

Probable signs of pregnancy include findings like soft cervix, ballottement, and a positive pregnancy test, but they do not confirm pregnancy alone.

Prompts	Presumptive	Probable	Positive
Auscultation of fetal heart tones heard via Doppler
Ultrasound verification of embryo or fetus
Amenorrhea
Fetal movement felt by experienced clinician
Chadwick’s sign
Positive HCG pregnancy test
Fatigue, nausea and vomiting
Breast tenderness

Prompts	True	False
The contractions subside with activity or rest
The contractions become progressively stronger and occur together
Uterine pains start in the lower back and radiate to the abdomen
Cervical dilation and effacement occur
Contractions are irregular and do not increase in intensity
Contractions become stronger and more intense with walking and activity

1 :
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

2 :
Select the corresponding signs of pregnancy with the prompts listed.

Correct Answers

4 :
Which of the following statements made by a woman during discharge teaching indicate the need for additional education about contraception? (Select all that apply.)

5 :
A nurse is caring for a patient in the third stage of labor, following the delivery of the newborn. Which of the following nursing actions is the priority to prevent complications during this stage?

6 :
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

7 :
The nurse is educating a pregnant woman about the differences between true labor and false labor. Which of the following statements are true regarding true labor and false labor?

Correct Answers

8 :
The nurse is explaining the difference between true labor and false labor to a pregnant client. Which of the following characteristics is most consistent with false labor?

9 :
Use the choices provided to fill in blank 1 and 2.

Correct Answers

10 :
A woman comes to the prenatal clinic suspecting that she is pregnant, and the assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? (Select all that apply.)

1 : A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

2 : Select the corresponding signs of pregnancy with the prompts listed.

Correct Answers

4 : Which of the following statements made by a woman during discharge teaching indicate the need for additional education about contraception? (Select all that apply.)

5 : A nurse is caring for a patient in the third stage of labor, following the delivery of the newborn. Which of the following nursing actions is the priority to prevent complications during this stage?

6 : The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

7 : The nurse is educating a pregnant woman about the differences between true labor and false labor. Which of the following statements are true regarding true labor and false labor?

Correct Answers

8 : The nurse is explaining the difference between true labor and false labor to a pregnant client. Which of the following characteristics is most consistent with false labor?

9 : Use the choices provided to fill in blank 1 and 2.

Correct Answers

10 : A woman comes to the prenatal clinic suspecting that she is pregnant, and the assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? (Select all that apply.)

1 :
A nurse is planning care for a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

2 :
Select the corresponding signs of pregnancy with the prompts listed.

4 :
Which of the following statements made by a woman during discharge teaching indicate the need for additional education about contraception? (Select all that apply.)

5 :
A nurse is caring for a patient in the third stage of labor, following the delivery of the newborn. Which of the following nursing actions is the priority to prevent complications during this stage?

6 :
The nurse institutes measure to maintain thermoregulation based on the understanding that newborns have limited ability to regulate body temperature because they:

7 :
The nurse is educating a pregnant woman about the differences between true labor and false labor. Which of the following statements are true regarding true labor and false labor?

8 :
The nurse is explaining the difference between true labor and false labor to a pregnant client. Which of the following characteristics is most consistent with false labor?

9 :
Use the choices provided to fill in blank 1 and 2.

10 :
A woman comes to the prenatal clinic suspecting that she is pregnant, and the assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? (Select all that apply.)