Nokea
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
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A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia.
- B. Increased feeding.
- C. Hyperthermia.
- D. Respiratory distress.
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate.
- B. Chin quivering.
- C. Pinpoint pupils.
- D. Slowed respirations.
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. Pain assessment in newborns can be challenging due to their limited ability to communicate. Chin quivering is a common behavioral indicator of pain in newborns. It is a subtle sign of distress and discomfort. Other choices such as decreased heart rate (A), pinpoint pupils (C), and slowed respirations (D) are not reliable indicators of pain in newborns. Decreased heart rate can indicate relaxation, pinpoint pupils are more indicative of opioid use, and slowed respirations might be a sign of sleepiness or relaxation rather than pain.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is because decreased temperature (B), lethargy (C), poor feeding (D), respiratory distress (E), and yellow sclera and oral mucosa (F) are consistent with hypoglycemia, hyperbilirubinemia, and sepsis. Decreased temperature can indicate hypoglycemia, lethargy and poor feeding can be seen in hypoglycemia and sepsis, respiratory distress can be a sign of sepsis, and yellow sclera and oral mucosa can be indicative of hyperbilirubinemia. Ecchymotic caput succedaneum is more related to birth trauma and is not specific to these conditions.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Place the client in a supine position for 30 min following the first dose of anesthetic solution.
- B. Administer 1,000 mL of dextrose 5% in water prior to the first dose of anesthetic solution.
- C. Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
- D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: Correct Answer: C - Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.
Rationale: Continuous monitoring of blood pressure is crucial after administering epidural anesthesia to detect any potential hypotension, a common side effect. This frequent monitoring allows for prompt intervention if hypotension occurs, ensuring the client's safety. It is essential to closely monitor the client's vital signs, particularly blood pressure, to prevent complications such as decreased placental perfusion and fetal distress.
Summary:
A: Placing the client in a supine position for 30 min following the first dose of anesthetic solution is not recommended as it can lead to aortocaval compression and compromise blood flow to the fetus.
B: Administering dextrose 5% in water prior to the first dose of anesthetic solution is not necessary for epidural anesthesia.
D: Ensuring the client has been NPO 4 hr prior to the placement of the epidural is