ANSWER KEY 14. B.

Telephone reports are used to communicate information about a client's transfer to and from another unit. The other options are not necessary. 15. B: A client is in the transitional phase. Multiparas are moved to the delivery room before complete dilation because delivery occurs more rapidly in these clients. Vital signs and fetal heart tones are monitored every 15 minutes. Encouraging position changes are suggested during the active phase, whereas administration of local anesthesia is done on the second stage of labor. 16. (D) Physiological Adaptation/ Integrity. On inspection of the perineum, if the umbilical cord is noted, the nurse immediately places the client into Trendelenburg position while pushing the presenting part upward to relieve the cord compression. This position is maintained, the physician is notified, and the nurse monitors the fetal heart rate. The client is transferred to the delivery room when prescribed by the physician. 17. (C) Nurses should be able to explore measures that assist the family to create a memory of the baby so that the existence of the child is confirmed and the parents can complete the grieving process. Option C addresses this issue and also demonstrates a caring and empathetic response. Options a, b and d are blocks to communication and devalue the parents feelings. 18. (B) Post term infants (born after the 42nd week of gestation exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 to 37 weeks of gestation) exhibits thick vernix covering the body, smooth soles without crease, and lanugo covering the entire body. 19. (B) Tachypnea, grunting, retractions and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome, which can occur in post term infants who have decreased amniotic fluid and are prone to cord compression. It develops when meconium in the amniotic fluid enters the lungs during labor. Transient tachypnea of the newborn is primarily found in infants delivered via Caesarian section. Respiratory distress syndrome is a complication of preterm infants. The symptoms noted in the question are unrelated to hypoglycemia.