Nokea
A client who is in labor states, 'I think my water just broke!' The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
- A. Notify the operating room team.
- B. Administer a fluid bolus of 500 mL.
- C. Administer oxygen via face mask.
- D. Place the client in Trendelenburg.
Correct Answer: D
Rationale: Trendelenburg positioning relieves umbilical cord compression, preventing fetal hypoxia in this emergency.
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Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?
- A. Administer antipyretic medication on a continuous basis.
- B. Continue strict monitoring of daily wet diapers for 1 week.
- C. Have the antibiotic trough level drawn within 3 days.
- D. Monitor the infant for response to auditory stimuli.
Correct Answer: D
Rationale: Monitoring auditory responses detects hearing loss, a common meningitis complication, requiring follow-up screening.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct Answer: A
Rationale: Preventing heat loss avoids cold stress, which can lead to respiratory distress and metabolic issues, critical for newborn survival.
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which are the 3 most likely reasons that the infant is crying?
- A. Hunger
- B. Opioid withdrawal
- C. Hemorrhage
- D. Separation anxiety
- E. Pain
- F. Hypovolemia
- G. Hypoxia
Correct Answer: A,E,F
Rationale: Hunger due to NPO status, postoperative pain, and hypovolemia from surgical fluid losses are likely causes of crying. No evidence supports withdrawal, hemorrhage, anxiety, or hypoxia.
The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?
- A. Avoid any smoking inside the house.
- B. Give infant the full course of antibiotics.
- C. Schedule visit for pneumococcal vaccine.
- D. Instill benzocaine otic drops regularly.
Correct Answer: D
Rationale: Benzocaine otic drops provide pain relief but do not prevent infections. Regular use may mask symptoms, delaying treatment. Avoiding smoke, completing antibiotics, and vaccinating reduce infection risk.
A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled 'Isoniazid Oral Solution, USP 50 mg per 5 mL.' How many mL should the nurse administer?
- A. 25 mL
Correct Answer: A
Rationale: For a 25 kg child, the dose is 250 mg/day (25 kg × 10 mg/kg). With a concentration of 50 mg/5 mL (10 mg/mL), the volume is 250 mg ÷ 10 mg/mL = 25 mL.