Nokea
A full-term newborn is being assessed by a nurse 15 minutes after birth. Which of the following findings requires intervention by the nurse?
- A. Heart rate 168/min
- B. Respiratory rate 18/min
- C. Tremors
- D. Fine crackles
Correct Answer: B
Rationale: Correct Answer: B (Respiratory rate 18/min)
Rationale: A normal respiratory rate for a newborn is 30-60 breaths/min. A rate of 18/min is below the normal range, indicating potential respiratory distress requiring immediate intervention to ensure adequate oxygenation.
Summary of other choices:
A: Heart rate 168/min - Normal range for a newborn is 120-160/min.
C: Tremors - Common in newborns due to immature nervous system, usually self-resolving.
D: Fine crackles - May be present due to residual amniotic fluid and typically resolve without intervention.
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When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?
- A. Blood-tinged sputum
- B. Dizziness
- C. Pallor
- D. Somnolence
Correct Answer: B
Rationale: The correct answer is B: Dizziness. Nifedipine is a calcium channel blocker that can cause hypotension, leading to dizziness. This is a common side effect and needs to be monitored to prevent falls or injury. Blood-tinged sputum (A) is not typically associated with nifedipine use. Pallor (C) is not a common manifestation of nifedipine side effects. Somnolence (D) is also not a common side effect of nifedipine. Dizziness is the most relevant and potentially harmful manifestation to monitor for in a client receiving nifedipine for preterm labor.
While caring for a newborn undergoing phototherapy to treat hyperbilirubinemia, which of the following actions should the nurse take?
- A. Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
- B. Keep the newborn in a shirt while under the phototherapy light.
- C. Apply a light moisturizing lotion to the newborn's skin.
- D. Turn and reposition the newborn every 4 hours while undergoing phototherapy.
Correct Answer: A
Rationale: Correct Answer: A - Cover the newborn's eyes with an opaque eye mask while under the phototherapy light.
Rationale:
1. Phototherapy light can cause eye damage, so covering the newborn's eyes with an opaque eye mask protects them.
2. Newborns' eyes are more sensitive to light, making eye protection crucial during phototherapy.
Summary of Incorrect Choices:
B: Keeping the newborn in a shirt won't protect the eyes from phototherapy light.
C: Applying lotion can interfere with the effectiveness of phototherapy and may cause skin irritation.
D: Turning and repositioning the newborn is important for comfort, but eye protection is the priority during phototherapy.
A client is to receive oxytocin to augment labor. Which finding contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations
- B. Moderate variability of the FHR
- C. Cessation of uterine dilation
- D. Prolonged active phase of labor
Correct Answer: A
Rationale: The correct answer is A. Late decelerations indicate fetal distress, suggesting compromised oxygenation. Starting oxytocin can further stress the fetus, worsening decelerations. Report to prevent harm. B is incorrect as moderate variability is a reassuring sign of fetal well-being. C is incorrect as cessation of uterine dilation may indicate uterine hyperstimulation, not fetal distress. D is incorrect as prolonged active labor phase alone doesn't necessarily contraindicate oxytocin, but it may require monitoring.
A nurse in a health clinic is reinforcing teaching about contraceptive use with a group of clients. Which of the following client statements demonstrates understanding?
- A. Using a water-soluble lubricant with condoms can help prevent breakage and ensure effectiveness in preventing pregnancy and STIs.
- B. A diaphragm should be removed 2 hours after intercourse.
- C. Oral contraceptives can worsen a case of acne.
- D. A contraceptive patch is replaced once a month.
Correct Answer: A
Rationale: The correct answer is A because using a water-soluble lubricant with condoms can indeed help prevent breakage and maintain effectiveness in preventing pregnancy and STIs. Water-based lubricants are safe to use with condoms as they do not weaken the latex.
Option B is incorrect as a diaphragm should be left in place for at least 6 hours after intercourse, not removed after 2 hours. Option C is also incorrect as oral contraceptives are known to improve acne in many cases. Option D is incorrect as a contraceptive patch is typically replaced weekly, not monthly.
A client at 42 weeks of gestation is having an ultrasound. For which of the following conditions should the nurse prepare for an amnioinfusion? (Select all that apply)
- A. Oligohydramnios
- B. Hydramnios
- C. Fetal cord compression
- D. Polyhydramnios
Correct Answer: A
Rationale: Rationale: A client at 42 weeks of gestation is at risk for oligohydramnios, which is associated with decreased amniotic fluid levels. Amnioinfusion can be used to increase amniotic fluid volume to prevent fetal cord compression and facilitate fetal movement during labor.
Summary:
- B: Hydramnios (excessive amniotic fluid) does not require amnioinfusion.
- C: Fetal cord compression is a reason for amnioinfusion, not a condition to prepare for.
- D: Polyhydramnios (excessive amniotic fluid) does not typically require amnioinfusion unless there are complicating factors.