Nokea
A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care?
- A. Urine toxicology screening.
- B. Notifying hospital security.
- C. Limiting contact with visitors.
- D. Contacting local law enforcement.
Correct Answer: A
Rationale: Urine toxicology screening is necessary to assess for potential drug exposure in the newborn, which can affect their health and care plan.
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After circumcision with a Plastibell, the nurse should instruct the neonate's mother to cleanse the circumcision site with which of the following?
- A. Warm water.
- B. Povidone-iodine (Betadine) solution.
- C. Diluted hydrogen peroxide.
Correct Answer: A
Rationale: Warm water is recommended for cleansing the circumcision site to keep it clean and promote healing without causing irritation.
A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?
- A. 2 months.
- B. 6 months.
- C. 8 months.
- D. 10 months.
Correct Answer: B
Rationale: Solid foods are introduced around 6 months when the infant's digestive system is more mature.
A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepregnant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is:
- A. 4 weeks.
- B. 6 weeks.
- C. 8 weeks.
- D. 12 weeks.
Correct Answer: D
Rationale: Returning to prepregnant weight typically takes about 12 weeks with proper diet and exercise.
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.
The nurse is monitoring a primiparous client with postpartum hemorrhage. Which intervention is the highest priority?
- A. Administer oxygen at 2 L/min.
- B. Insert a second IV line.
- C. Massage the fundus vigorously.
- D. Administer methylergonovine as ordered.
Correct Answer: B
Rationale: Inserting a second IV line ensures access for fluid resuscitation, critical in managing hemorrhage.