Nokea
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis
- B. Single palmar creases
- C. Subconjunctival hemorrhage
- D. Rust-stained urine
Correct Answer: B
Rationale: The correct answer is B: Single palmar creases. This finding may indicate the presence of Down syndrome or other genetic disorders. The presence of single palmar creases warrants further evaluation by the provider to rule out any underlying conditions. Transient circumoral cyanosis, subconjunctival hemorrhage, and rust-stained urine are common and typically benign findings in newborns that do not require immediate reporting.
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A nurse is caring for a client who has gestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse the client has hyperglycemia?
- A. Double vision
- B. Increased urination
- C. Sweating
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Increased urination. Hyperglycemia in gestational diabetes mellitus leads to elevated blood glucose levels, causing the kidneys to filter excess glucose into the urine, leading to increased urination (polyuria). This is due to the osmotic effect of glucose drawing water from the body into the urine. Double vision (choice A) is more indicative of neurological issues. Sweating (choice C) can be a response to hypoglycemia rather than hyperglycemia. Dizziness (choice D) can be a symptom of both hyperglycemia and hypoglycemia, but it is not specific to hyperglycemia.
A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to immunize the client with which of the following vaccinations? Select all that apply.
- A. Varicella
- B. Human papillomavirus
- C. Diphtheria - acellular pertussis
- D. Inactivated influenza
Correct Answer: C,D
Rationale: The correct vaccinations for a pregnant client at 30 weeks gestation are C: Diphtheria-acellular pertussis (Tdap) and D: Inactivated influenza. Tdap is recommended during every pregnancy to protect the newborn from whooping cough, and influenza vaccine is safe and crucial to prevent flu-related complications. Varicella (A) and Human papillomavirus (B) vaccines are contraindicated during pregnancy due to potential risks to the fetus. Additionally, the incomplete choices (E, F, G) do not align with the recommended vaccinations during pregnancy.
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
- A. Expect 2 to 4 wet diapers every 24 hours
- B. Allow the baby to feed at least every 3 hours
- C. Offer the newborn 30 mL (1 oz.) of water between feedings
- D. Feed the newborn 5 to 10 minutes per breast
Correct Answer: B
Rationale: The correct answer is B: Allow the baby to feed at least every 3 hours. This is important for maintaining the baby's hydration, ensuring proper nutrition, and promoting successful breastfeeding. Feeding on demand helps establish a good milk supply and supports the baby's growth and development. Offering water (choice C) is unnecessary and can interfere with breastfeeding. Limiting feeding time to 5-10 minutes per breast (choice D) can prevent the baby from getting enough hindmilk, which is rich in fat and important for weight gain. Expecting 2-4 wet diapers every 24 hours (choice A) is a general guideline but not as crucial as ensuring frequent feedings for a breastfeeding newborn.
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.