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A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: Correct Answer: C - Initiate seizure precautions.
Rationale: Infants with neonatal abstinence syndrome are at risk for seizures due to drug withdrawal. Initiating seizure precautions involves creating a safe environment to prevent injury during a seizure. This includes padding the crib, ensuring a clear space around the infant, and having emergency medications available. Monitoring blood glucose levels every hour (A) is not directly related to neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a basic positioning technique and does not address the specific needs of a baby with neonatal abstinence syndrome. Providing a stimulating environment (D) is contraindicated as it can exacerbate symptoms of withdrawal in the infant.
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A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Assessing the newborn's latch while breastfeeding is crucial in addressing sore nipples. A poor latch can lead to nipple pain. By ensuring proper latch, the nurse can help alleviate the client's discomfort. Other actions are incorrect:
A: Waiting 4 hr between feedings can lead to engorgement and worsen nipple soreness.
C: Limiting breastfeeding time to 5 min can hinder milk supply and not address the root cause.
D: Offering supplemental formula can interfere with establishing breastfeeding and may not address the latch issue.
A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?
- A. Perform a vaginal examination by applying upward pressure on the presenting part.
- B. Cover the umbilical cord with a sterile saline-saturated towel.
- C. Administer oxygen via nonrebreather mask at 8 L/min.
- D. Initiate an infusion of IV fluids for the client.
Correct Answer: B
Rationale: The correct answer is B: Cover the umbilical cord with a sterile saline-saturated towel. This action is essential to prevent compression and drying of the umbilical cord, which could lead to fetal hypoxia and compromise fetal circulation. By covering the umbilical cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain fetal perfusion until delivery can be expedited. Performing a vaginal examination (choice A) could further compress the cord and worsen the situation. Administering oxygen (choice C) may be beneficial but is not the priority in this urgent situation. Initiating IV fluids (choice D) is not the immediate priority when fetal bradycardia and umbilical cord prolapse are present.
A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?
- A. Temperature 37.4°C (99.3°F)
- B. WBC count 9,000/mm3
- C. Uterine tenderness
- D. Scant lochia
Correct Answer: C
Rationale: The correct answer is C: Uterine tenderness. Endometritis is an infection of the uterine lining, which causes inflammation and tenderness in the uterus. This finding is expected in a client with endometritis.
A: Temperature of 37.4°C is within normal range postpartum and not specific to endometritis.
B: WBC count of 9,000/mm3 is within normal range and may not be significantly elevated in endometritis.
D: Scant lochia may not be a specific finding for endometritis as lochia changes can vary postpartum.
A nurse is assessing a client who is postpartum following a cesarean birth. The client states, 'I feel like I have to urinate but I can’t go.' Which of the following actions should the nurse take?
- A. Assist the client to ambulate to the bathroom
- B. Insert an indwelling urinary catheter
- C. Perform a bladder scan to assess for urinary retention
- D. Administer a diuretic
Correct Answer: A
Rationale: Correct Answer: A. Assist the client to ambulate to the bathroom.
Rationale: By assisting the client to ambulate to the bathroom, the nurse is promoting normal physiological functioning. Walking can help stimulate the bladder and promote urination, which is often needed after a cesarean birth due to the effects of anesthesia and limited mobility. It also helps prevent complications like urinary retention or urinary tract infections. Encouraging the client to move also aids in promoting circulation, preventing blood clots, and enhancing overall recovery.
Summary of other choices:
B: Inserting an indwelling catheter should not be the first intervention as it can increase the risk of infection and discomfort.
C: Performing a bladder scan is not necessary as the client's symptoms do not indicate a need for immediate assessment of urine volume.
D: Administering a diuretic is not appropriate without assessing the client's condition further as it may not address the underlying issue and could exacerbate any existing problems.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on skeletal muscle and cardiac function. It is essential to have calcium gluconate readily available in case of magnesium toxicity.
Incorrect Choices:
A: Restricting hourly fluid intake is not necessary for a client with preeclampsia receiving magnesium sulfate IV.
C: Assessing deep tendon reflexes every 6 hours is not the most critical action to take to prevent or manage magnesium toxicity.
D: Monitoring intake and output every 4 hours is important for overall client assessment but is not directly related to managing magnesium toxicity in this scenario.