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A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate a serious condition like preeclampsia, a potentially life-threatening pregnancy complication. The nurse should instruct the client to report this immediately to the provider for further evaluation and management. Shortness of breath when climbing stairs (A), swelling of feet and ankles at the end of the day (B), and Braxton Hicks contractions (D) are common occurrences in pregnancy and not usually indicative of immediate complications. Therefore, they do not require urgent reporting compared to the unrelieved headache as mentioned in choice C.
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A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. This requires immediate medical attention to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically alarming.
C: Nosebleeds are common in pregnancy due to increased blood volume and hormonal changes, and occurring three times per week is not unusual.
D: Increased vaginal discharge is a common symptom of early pregnancy due to hormonal changes and increased blood flow to the pelvic area, which is typically not concerning.
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Feed the newborn 5 to 10 min per breast.
- B. Offer the newborn 30 mL (1 oz) of water between feedings.
- C. Expect two to four wet diapers every 24 hr.
- D. Allow the baby to feed at least every 3 hr.
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hr. This instruction is important for establishing and maintaining a good milk supply, promoting proper infant growth and development, and preventing common breastfeeding issues like engorgement and mastitis. Feeding on demand also helps ensure the baby receives enough nutrients and helps establish a strong breastfeeding relationship.
A: Feed the newborn 5 to 10 min per breast - This is incorrect as it may not allow the baby to get enough hindmilk, which is essential for proper growth.
B: Offer the newborn 30 mL (1 oz) of water between feedings - Giving water to newborns can interfere with breastfeeding and may lead to water intoxication.
C: Expect two to four wet diapers every 24 hr - While monitoring diaper output is important, this alone does not provide adequate guidance on feeding frequency.
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: Correct Answer: D - Respiratory distress
Rationale: Hypoglycemia in a late preterm newborn can lead to respiratory distress due to inadequate glucose supply to the brain, causing dysfunction in respiratory centers. This can manifest as tachypnea, grunting, nasal flaring, and retractions. Hypertonia, increased feeding, and hyperthermia are not specific signs of hypoglycemia in newborns.
Summary:
A: Hypertonia is not a typical manifestation of hypoglycemia in newborns.
B: Increased feeding is more likely to be seen in newborns with hunger cues, not necessarily indicative of hypoglycemia.
C: Hyperthermia is not a common sign of hypoglycemia in newborns.
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia is a common cause. Low blood glucose in a newborn can lead to seizures and long-term neurological damage. Monitoring blood glucose levels and promptly addressing any abnormalities is crucial. Total bilirubin (B) is important for assessing jaundice, not jitteriness. Hemoglobin (C) and blood calcium (D) are not typically related to jitteriness in a newborn.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. This is the recommended site for administering vaccines to newborns due to the large muscle mass, reducing the risk of injury to nerves and blood vessels. It also allows for proper absorption of the vaccine. Option B is incorrect as vigorous massage can lead to tissue damage and discomfort. Option C is incorrect as the needle should be inserted at a 90° angle for intramuscular injections. Option D is incorrect as a smaller gauge needle (typically 25-27 gauge) is recommended for newborns to minimize pain and tissue trauma.