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A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
- A. Pain level
- B. Blood pressure
- C. Infusion site
- D. Contraction pattern
Correct Answer: D
Rationale: When a client is receiving oxytocin to augment labor, the most crucial assessment for the nurse to obtain each time the infusion rate is increased is monitoring the contraction pattern. Increasing the infusion rate of oxytocin can lead to stronger and more frequent contractions, which can have implications for both the mother and the baby. Monitoring the contraction pattern helps ensure the safe administration of oxytocin and allows for timely interventions if needed.
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After breastfeeding for 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?
- A. Wipe away the spit-up and assist the mother with the diaper change.
- B. Sit the newborn upright and burp by rubbing or patting the upper back.
- C. Place the newborn in a position with the head lower than the feet.
- D. Turn the newborn to the side and use bulb suction for the mouth and nares.
Correct Answer: B
Rationale: After a newborn spits up breast milk following feeding, the priority action for the nurse is to sit the newborn upright and burp by rubbing or patting the upper back. This position helps release trapped air and reduces the likelihood of further spit-up or aspiration. It is essential to address this first to prevent potential complications and ensure the newborn's comfort and safety.
The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside?
- A. Litmus paper.
- B. Fetal scalp electrode.
- C. A sterile glove.
- D. Needle and Thread
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When teaching a gravid client how to perform kick (fetal movement) counts, which instruction should the nurse include?
- A. If 10 kicks are not felt within one hour, drink orange juice and count for another hour.
- B. Count the movements once daily, for one hour, before breakfast.
- C. Avoid caffeinated drinks for 24 hours before conducting the kick test.
- D. Exercise for 15 minutes before starting the counting to help increase fetal movement.
Correct Answer: A
Rationale: When teaching a gravid client about kick (fetal movement) counts, the nurse should instruct them that if 10 kicks are not felt within one hour, they should drink orange juice and continue counting for another hour. This instruction is crucial as a drop in fetal movements could indicate potential issues with fetal well-being, and taking action such as rechecking after food intake is recommended to monitor the situation closely.
Immediately after birth, a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has spontaneous respirations, and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20 breaths/minute. What action should the nurse take next?
- A. Initiate positive pressure ventilation.
- B. Intervene after the one-minute Apgar assessment.
- C. Initiate CPR on the infant.
- D. Assess the infant's blood glucose level.
Correct Answer: A
Rationale: A heart rate below 100 bpm in a newborn indicates bradycardia and requires intervention. Positive pressure ventilation should be initiated to improve oxygenation and help increase the infant's heart rate. This intervention is crucial to support the newborn's transition to extrauterine life and prevent further complications.
After each feeding, a 3-day-old newborn is spitting up large amounts of Enfamil® Newborn Formula, a nonfat cow's milk formula. The pediatric healthcare provider changes the neonate's formula to Similac® Soy Isomil® Formula, a soy protein isolate-based infant formula. What information should the LPN/LVN provide to the mother about the newly prescribed formula?
- A. The new formula is a coconut milk formula used with babies with impaired fat absorption.
- B. Enfamil® Formula is a demineralized whey formula that is needed with diarrhea.
- C. The new formula is a casein protein source that is low in phenylalanine.
- D. Similac® Soy Isomil® Formula is a soy-based formula that contains sucrose.
Correct Answer: D
Rationale: The LPN/LVN should inform the mother that Similac® Soy Isomil® Formula is a soy-based formula containing sucrose. This formula is suitable for infants with cow's milk protein allergy or intolerance, which may be the reason for the newborn spitting up large amounts of the previous cow's milk formula.