Nokea
A client who is pregnant and has phenylketonuria (PKU) is receiving teaching from a nurse. Which of the following foods should the nurse instruct the client to eliminate from her diet?
- A. Peanut butter
- B. Potatoes
- C. Apple juice
- D. Broccoli
Correct Answer: A
Rationale: The correct answer is A: Peanut butter. Phenylketonuria (PKU) is a metabolic disorder where the body can't process phenylalanine found in protein foods. Peanut butter is high in protein and contains phenylalanine, so it should be eliminated from the client's diet. Potatoes, apple juice, and broccoli are low in protein and do not contain high levels of phenylalanine, so they do not need to be eliminated. It is crucial for the client to avoid foods high in phenylalanine to prevent the buildup of toxic levels in the body, which can lead to serious health issues.
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A healthcare provider is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 22/min
- B. 48/min
- C. 100/min
- D. 110/min
Correct Answer: B
Rationale: The correct answer is B: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. It is important to assess a newborn's respiratory rate to ensure proper oxygenation. Option A (22/min) is too low, while options C (100/min) and D (110/min) are too high and could indicate respiratory distress or other issues that need immediate attention. Therefore, option B falls within the expected reference range and is the correct answer for a healthy newborn assessment.
When should a provider order a maternal serum alpha-fetoprotein (MSAFP) screening for pregnant clients?
- A. A client who has mitral valve prolapse
- B. A client who has been exposed to AIDS
- C. All pregnant clients
- D. A client who has a history of preterm labor
Correct Answer: C
Rationale: Rationale:
- MSAFP screening is recommended for all pregnant clients to assess risk of neural tube defects or chromosomal abnormalities.
- It is a standard prenatal test regardless of specific medical conditions.
- Options A, B, and D are not directly related to the indication for MSAFP screening in pregnancy.
When reinforcing teaching with a group of new parents about proper techniques for bottle feeding, which of the following instructions should be provided?
- A. Burp the newborn at the end of the feeding
- B. Hold the newborn close in a supine position
- C. Keep the nipple full of formula throughout the feeding
- D. Refrigerate any unused formula
Correct Answer: C
Rationale: Rationale:
C is correct because keeping the nipple full of formula throughout the feeding helps prevent the baby from swallowing air, reducing the risk of gas and colic. A is incorrect because burping should be done mid-feeding. B is incorrect because newborns should be held in an upright position while feeding to prevent choking. D is incorrect because unused formula should be discarded within 1-2 hours, not refrigerated.
While assisting with the care of an infant with a high bilirubin level receiving phototherapy, which finding should the nurse prioritize for reporting to the charge nurse?
- A. Conjunctivitis
- B. Bronze skin discoloration
- C. Sunken fontanels
- D. Maculopapular skin rash
Correct Answer: C
Rationale: The correct answer is C: Sunken fontanels. This finding indicates dehydration in the infant, which can be a serious complication requiring immediate intervention. Dehydration can lead to further elevation of bilirubin levels and potential neurological complications. Reporting this to the charge nurse is crucial for prompt assessment and intervention.
Incorrect choices:
A: Conjunctivitis - Although important, it is not a priority over a sign of dehydration.
B: Bronze skin discoloration - This may be a common side effect of phototherapy and does not indicate an urgent issue.
D: Maculopapular skin rash - While it should be monitored, it does not take precedence over a sign of dehydration.
During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?
- A. Apply palms of both hands to sides of the uterus
- B. Palpate the fundus of the uterus
- C. Grasp the lower uterine segment between thumb and fingers
- D. Stand facing the client's feet with fingertips outlining cephalic prominence
Correct Answer: B
Rationale: The correct answer is option B: Palpate the fundus of the uterus. This technique helps the nurse identify the fetal lie by feeling for the position of the baby's head or buttocks at the top of the uterus. By palpating the fundus, the nurse can determine whether the baby is in a vertex (head down) or breech (head up) position. This method is effective in assessing the fetal lie as it provides direct information about the baby's orientation within the uterus.
Option A is incorrect because applying palms to the sides of the uterus does not specifically help identify the fetal lie. Option C is incorrect as grasping the lower uterine segment does not provide information on the fetal lie. Option D is incorrect because standing facing the client's feet with fingertips outlining cephalic prominence is not a technique used to determine fetal lie.