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Client in latent phase of labor for 12 hours, requesting medication to rest
A client in latent phase of labor for the past 12 hours is requesting medication to help her rest.
- A. Fentanyl
- B. Meperidine.
- C. Morphine.
- D. Secobarbital.
- E. Secobarbital.
Correct Answer: A
Rationale: Fentanyl is a fast-acting opioid suitable for pain relief and sedation in labor, with less risk of prolonged effects compared to other options.
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Newborn, 2 days old, lost 6 ounces since birth
A mother is upset because her newborn has lost 6 ounces since birth 2 days ago. The nurse informs the mother that it is normal for a newborn to lose which percentage of their birth weight within the first week of life?
- A. 10% to 15% of their birth weight.
- B. 20% of their birth weight.
- C. 15% to 18% of their birth weight.
- D. 5% to 10% of their birth weight.
Correct Answer: D
Rationale: 5% to 10% of their birth weight is correct because this range is within the normal limits for a newborn weight loss. Newborns lose some weight due to insufficient caloric intake, fluid loss, and metabolic adjustments in the first week after birth.
Newborn 1 hour after birth, axillary temperature 95.8°F, apical pulse 114 bpm, respiratory rate 60 breaths/minute
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
- A. Hypothermia.
- B. Deficient fluid volume.
- C. Impaired gas exchange.
- D. Risk for infection.
Correct Answer: A
Rationale: The low temperature (95.8°F) indicates hypothermia, a priority due to risks of hypoglycemia, acidosis, and impaired oxygen delivery.
WIC program
The Women, Infants, and Children (WIC) program provides
- A. immunizations for high-risk infants and children.
- B. screening for infants with developmental disorders.
- C. supplemental food supplies to low-income pregnant or breastfeeding women.
- D. well-child examinations for infants and children living at the poverty level.
Correct Answer: C
Rationale: WIC provides supplemental food supplies to low-income pregnant or breastfeeding women and children up to age 5 at nutritional risk.
Woman received 50 mcg fentanyl intravenously 1 hour before delivery
A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?
- A. Nalbuphine (Nubain).
- B. Naloxone (Narcan).
- C. Butorphanol (Stadol).
- D. Promethazine (Phenergan).
Correct Answer: B
Rationale: Naloxone (Narcan) reverses opioid effects like fentanyl, critical for addressing potential respiratory depression in the newborn.
Client after amniotomy
After an amniotomy, which action by the nurse takes priority?
- A. Change the patient's gown.
- B. Assess the fetal heart rate.
- C. Estimate the amount of amniotic fluid.
- D. Assess the color of the amniotic fluid.
Correct Answer: B
Rationale: Assessing the fetal heart rate is the priority after an amniotomy to ensure the fetus tolerates the procedure and detect any distress.