Nokea
A client is experiencing preterm labor and is receiving betamethasone. Which of the following statements by the client indicates an understanding of the medication?
- A. This medication will help prevent contractions.
- B. This medication will reduce my baby's risk of respiratory distress.
- C. This medication will prevent early labor.
- D. This medication will increase my baby's weight.
Correct Answer: B
Rationale: Correct answer: Option B. Betamethasone is a glucocorticoid used to promote fetal lung maturity and reduce the risk of respiratory distress syndrome in preterm infants. Option A is incorrect because betamethasone does not prevent contractions. Option C is incorrect as betamethasone does not prevent early labor but helps improve fetal lung development. Option D is incorrect as betamethasone does not increase the baby's weight.
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A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?
- A. Continue to monitor the fetal heart rate
- B. Reposition the client
- C. Administer oxygen via face mask
- D. Increase the rate of the IV fluids
Correct Answer: A
Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.
A nurse is assessing a newborn who is 1 day old. Which of the following findings should the nurse report to the provider?
- A. Heart rate 160/min
- B. Axillary temperature 36.8°C (98.2°F)
- C. Yellow-tinged skin
- D. Respiratory rate 42/min
Correct Answer: C
Rationale: The correct answer is C: Yellow-tinged skin. Yellow-tinged skin within the first 24 hours of life can indicate pathological jaundice and should be reported to the provider. High heart rate (Choice A), normal axillary temperature (Choice B), and slightly elevated respiratory rate (Choice D) are common findings in newborns and may not necessarily require immediate reporting unless they persist or are significantly abnormal.
A nurse is providing discharge teaching to a client who is postpartum and has a prescription for methylergonovine. The nurse should instruct the client to report which of the following adverse effects?
- A. Headache
- B. Diarrhea
- C. Nausea
- D. Increased vaginal bleeding
Correct Answer: A
Rationale: The correct answer is A: Headache. Methylergonovine can cause vasoconstriction, leading to headaches. It is important for the client to report this adverse effect to the provider as it may indicate a serious complication. Choices B, C, and D are incorrect because methylergonovine is not typically associated with diarrhea, nausea, or increased vaginal bleeding as common adverse effects.
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Swaddle the newborn tightly
- B. Provide frequent tactile stimulation
- C. Position the newborn in a prone position
- D. Offer large feedings every 4 hours
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a newborn with neonatal abstinence syndrome is to swaddle the newborn tightly. Swaddling helps to provide comfort and reduce irritability in these newborns. Choice B, providing frequent tactile stimulation, may exacerbate the symptoms of neonatal abstinence syndrome by overstimulating the newborn. Choice C, positioning the newborn in a prone position, is not recommended as it increases the risk of sudden infant death syndrome (SIDS). Choice D, offering large feedings every 4 hours, is not appropriate as newborns with neonatal abstinence syndrome may have feeding difficulties and need smaller, more frequent feedings.
A nurse is caring for a newborn who is 2 days old and has a total serum bilirubin level of 18 mg/dL. Which of the following interventions should the nurse implement?
- A. Administer 1 oz of glucose water every 2 hours
- B. Feed the newborn 60 mL of formula every 4 hours
- C. Offer sterile water between feedings
- D. Initiate phototherapy
Correct Answer: D
Rationale: The correct answer is D: Initiate phototherapy. Phototherapy is the primary treatment for a newborn with hyperbilirubinemia, as it helps to break down excess bilirubin in the skin. Administering glucose water (choice A) is not indicated for treating hyperbilirubinemia. Feeding the newborn formula (choice B) or offering sterile water (choice C) will not directly address the elevated bilirubin levels in the newborn.