Nokea
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn's visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: Neonatal abstinence syndrome (NAS) occurs in newborns who were exposed to addictive drugs in utero, commonly seen in infants born to mothers with substance use disorders. These babies often experience withdrawal symptoms such as tremors, irritability, and difficulty sleeping. Swaddling the newborn in a flexed position can help provide comfort and security to the infant, which may help alleviate some of the withdrawal symptoms they are experiencing. This intervention can also mimic the snug environment of the womb, promoting a sense of calmness for the newborn. It is important to create a soothing environment to aid in the management of NAS symptoms.
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A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor Tracing. Which of the following action should the nurse take?
- A. Decrease maintenance IV solution infusion rate.
- B. Place the client in lateral position.
- C. Administer misoprostol 25 mcg vaginally D
- D. Administer oxygen via face mask at 2 L/min
Correct Answer: B
Rationale: Late decelerations of the fetal heart rate can indicate uteroplacental insufficiency, which may be a result of decreased oxygen supply to the fetus. Placing the client in a lateral position can help enhance uteroplacental perfusion by relieving pressure on the vena cava and improving maternal blood flow to the placenta. This position change can help improve fetal oxygenation and decrease the occurrence of late decelerations. Other actions such as administering oxygen and assessing for other contributing factors should also be done, but placing the client in a lateral position is the most appropriate immediate intervention in this scenario.
What is the priority nursing action when shoulder dystocia is encountered during delivery?
- A. Apply fundal pressure
- B. Call for additional assistance
- C. Perform the McRoberts maneuver
- D. Encourage the mother to push harder
Correct Answer: C
Rationale: The McRoberts maneuver widens the pelvic outlet for delivery.
A nurse is caring for a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take?
- A. Place a snug dressing on the client's nipple when not breastfeeding.
- B. Ensure the newborn's mouth is wide open before latching to the breast.
- C. Encourage the client to limit the newborn's feeding to 10 min on each breast.
- D. Instruct the client to begin the feeding with the nipple that is most tender.
Correct Answer: B
Rationale: Ensuring the newborn's mouth is wide open before latching to the breast is the correct action to take when caring for a client experiencing sore nipples from breastfeeding. When the newborn latches onto the breast correctly with a wide open mouth, it helps to prevent nipple soreness and discomfort by allowing proper positioning and attachment, which reduces pressure on the nipple. This action can promote effective and comfortable breastfeeding for both the client and the newborn. Placing a snug dressing on the nipple when not breastfeeding (Choice A) could hinder air circulation, leading to moisture, which may increase the risk of nipple soreness. Limiting the newborn's feeding to 10 minutes on each breast (Choice C) can be insufficient for adequate milk intake and can lead to feeding issues. Instructing the client to begin the feeding with the nipple that is most tender (Choice D) may exacerbate the issue and cause further discomfort.
A pregnant client asks why she needs to avoid lying on her back during the third trimester. What is the best response?
- A. Lying on your back increases the risk of preterm labor.
- B. Lying on your back can reduce blood flow to your baby.
- C. Lying on your back causes increased fetal movements.
- D. Lying on your back is uncomfortable for most women.
Correct Answer: B
Rationale: Supine positioning can compress the vena cava, reducing blood flow to the fetus.
What symptom is related to perimenopausal hormone fluctuations? Select all that apply.
- A. musculoskeletal complaints
- B. heart palpitations
- C. sleeping difficulties
- D. severe pelvic pain
Correct Answer: A,B,C
Rationale: