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A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to addictive substances in utero. Excessive crying is a common manifestation due to neurological irritability. Diminished deep tendon reflexes (A) would not be expected as the central nervous system is hyperactive. Decreased muscle tone (C) is unlikely as muscle rigidity or tremors are more common. Absent Moro reflex (D) is not typically seen as it is a primitive reflex present in newborns.
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A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D because delaying the instillation of antibiotic ophthalmic ointment can facilitate bonding between the newborn and parent, promoting skin-to-skin contact and eye contact essential for bonding. This crucial time immediately following birth sets the foundation for a strong parent-child relationship.
Summary:
A: Incorrect. Delaying antibiotic ointment instillation does not help in identifying infection manifestations.
B: Incorrect. The newborn's weight is not a factor in delaying the instillation of ointment.
C: Incorrect. The mode of delivery does not impact the timing of antibiotic ointment application.
D: Correct. Delaying ointment instillation facilitates bonding between the newborn and parent.
E, F, G: N/A
A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effects should the nurse include?
- A. Breast tenderness
- B. Tinnitus
- C. Urinary frequency
- D. Chills
Correct Answer: A
Rationale: The correct answer is A: Breast tenderness. Clomiphene citrate is a medication commonly used to treat infertility by stimulating ovulation. Breast tenderness is a common side effect due to the hormonal changes it induces, as it can lead to increased estrogen levels. This is important for the nurse to include in teaching as it prepares the client for a potential adverse effect.
B: Tinnitus, C: Urinary frequency, D: Chills are not typically associated with clomiphene citrate use. Tinnitus is more commonly linked to ototoxic medications, urinary frequency is not a known side effect of clomiphene, and chills are not a typical reaction to this medication. It is essential for the nurse to focus on the most relevant and common adverse effects to ensure the client's understanding and safety.
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 important to prevent compression of the umbilical cord, which can lead to decreased blood flow to the fetus resulting in fetal distress or demise. By covering the protruding cord with a sterile saline-saturated towel, the nurse can protect the cord and maintain adequate blood flow until further interventions can be performed by the healthcare team. Performing a vaginal examination by applying upward pressure on the presenting part (choice A) can further compress the cord and worsen the situation. Administering oxygen via nonrebreather mask (choice C) and initiating an infusion of IV fluids (choice D) are important interventions but should be done after addressing the umbilical cord protrusion to ensure adequate oxygenation and perfusion to the fetus.
A nurse is reviewing the prescriptions for a client who is pregnant and is taking digoxin. Which of the following actions should the nurse take to best evaluate the client’s medication adherence?
- A. Ask the client if they are taking the medication as prescribed.
- B. Assess the client’s kidney function.
- C. Determine the client’s apical pulse rate.
- D. Check the client’s serum medication level.
Correct Answer: D
Rationale: The correct answer is D: Check the client’s serum medication level. This is the best way to evaluate medication adherence for a client taking digoxin during pregnancy. Digoxin has a narrow therapeutic range, and monitoring the serum level helps ensure the client is taking the medication as prescribed. Option A is not as reliable as self-reporting may not be accurate. Option B, assessing kidney function, is important but not directly related to medication adherence. Option C, determining the apical pulse rate, may indicate the medication's effectiveness but does not confirm adherence. Checking the serum medication level directly assesses the actual drug concentration in the body, providing concrete evidence of adherence.
A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). At 20 weeks of gestation, elevated blood glucose levels can indicate gestational diabetes, posing risks for both the mother and fetus. The normal range for fasting blood glucose is 74 to 106 mg/dL, so a value of 180 mg/dL is significantly high. The nurse should report this finding to the provider promptly for further evaluation and management to prevent complications.
A: Hematocrit of 37% is within the normal range for pregnancy.
B: Creatinine level of 0.9 mg/dL falls within the normal range.
C: WBC count of 11,000/mm3 is slightly elevated but can be attributed to the normal physiological changes in pregnancy, such as increased demand on the immune system.
Therefore, choices A, B, and C are not significantly concerning at this stage of gestation compared to the high blood glucose