A nurse is assessing a newborn who is 12 hr old. Which of the following
manifestations requires intervention by the nurse? - A. Acrocyanosis of the
extremities
B. Murmur at the left sternal border
C. Substernal chest retractions while sleeping
D. Positive Babinski reflex
Answer: Substernal chest retractions while sleeping
A. Acrocyanosis of the extremities
Acrocyanosis of the extremities is an expected manifestation in newborns.
Acrocyanosis is a bluish discoloration of the newborn's hands and feet.
B. Murmur at the left sternal border
An audible murmur heard at the left sternal border is an expected
manifestation in newborns.
C. Substernal chest retractions while sleeping
Substernal chest retractions can indicate respiratory distress syndrome in the
newborn. This manifestation requires further assessment and intervention by
the nurse.
D. Positive Babinski reflex
A positive Babinski reflex is an expected manifestation in newborns. This
reflex is elicited when a newborn's sole is stroked with a finger upward along
the lateral aspect of the sole and then across the ball of the foot and, in
response, the t
FHR can be heard by a doppler at - 10-12 weeks gestation
when should a nurse start measuring a woman's fundal height? - after 12
weeks gestation
between 18-30 weeks the fundal height should measure what? - it should
equal the week of gestation
MSAFP screening is done at - 15-22 weeks gestation
, smoking tobacco during pregnancy is associated with - low birth weight
pregnant women should consume how much water each day? - 2-3 liters
of water each day
regarding kick counts what are the signs the woman needs further evaluation?
- there are less than 3 kicks in one hour or there are no signs of fetal
movement for 12 hours
recommended weight gain during pregnancy - 25-30 pounds, 3-4 pounds
first trimester and 1 pound per week last two trimesters
foods high in folic acid - leafy greens, dried peas, dried beans, seeds,
orange juice
recommended amount of folic acid intake during pregnancy - 600 mcg
recommended folic acid intake for lactating pregnant women - 500 mcg
what vitamin increases absorption of iron - vitamin c
client's bladder needs to be ____ before an ultrasound - full
BPP normal score - 8-10
BPP abnormal score - less than 4
if a BPP comes back as a 6 - it should be retested
BPP assesses for - fetal well being
non stress test (NST) - assesses fetal well being during third trimester
reactive NST - normal FHR baseline with moderate variability and two
accelerations 15 beats per minute for at least 15 seconds over 20 minute
period
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