A mother's laboratory results indicate the presence of cocaine and alcohol. The characteristic in her newborn that would indicate to the nurse that the baby has been affected with fetal alcohol syndrome would be:
- A. Cleft lip
- B. Polydactyly
- C. Umbilical Hernia
- D. Small upturned nose neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am ï‚· Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain ï‚· Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr. ï‚· Mom may breastfeed ad lib ï‚· Draw blood cultures x 3 in A.M. ï‚· Urine C&S in A.M.
Correct Answer: D
Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.
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The nurse is assessing a client who reports vaginal bleeding at 20 weeks' gestation. What is the priority action?
- A. Assess the amount and color of bleeding.
- B. Place the client in a Trendelenburg position.
- C. Administer Rho(D) immune globulin.
- D. Perform a vaginal examination.
Correct Answer: A
Rationale: Assessing the bleeding provides critical information to determine the next steps and evaluate potential complications.
A client at 32 weeks' gestation reports regular uterine contractions every 10 minutes. What is the nurse's priority action?
- A. Administer tocolytic medication as prescribed.
- B. Perform a sterile vaginal examination.
- C. Assess for cervical changes and fetal heart rate.
- D. Encourage ambulation to relieve discomfort.
Correct Answer: C
Rationale: Assessing cervical changes and fetal heart rate is essential to determine whether the client is in preterm labor.
The nurse is educating a client about exercises during pregnancy. What activity should be avoided?
- A. Swimming.
- B. Walking.
- C. Contact sports.
- D. Prenatal yoga.
Correct Answer: C
Rationale: Contact sports pose a risk of trauma to the mother and fetus and should be avoided during pregnancy.
Which newborn is at highest risk of a skin infection? of the FHR?
- A. Infant born at 36 weeks who is being bottle fed
- B. Right lower abdomen
- C. Infant whose umbilical cord fell off on day 8 of life
- D. Near client umbilicus
Correct Answer: C
Rationale: The newborn infant whose umbilical cord fell off on day 8 of life is at highest risk of a skin infection. This is because the umbilical cord stump is an area prone to bacterial colonization and can lead to infection if proper care is not maintained during the cord care period. Once the umbilical cord falls off, the skin in that area is exposed and vulnerable to infection. It is important to educate parents on proper cord care techniques to prevent infection in this high-risk period.
When the nurse is assisting a person desiring contraception, a history and physical is done. What is an important question the nurse should ask?
- A. What is your education level?
- B. Have you ever been pregnant?
- C. Are you married?
- D. What is your exercise routine?
Correct Answer: B
Rationale: When assisting a person desiring contraception, asking whether they have ever been pregnant is an important question because it helps the healthcare provider assess the individual's past reproductive history, including any pregnancies and potential complications. This information is important in determining the most suitable contraceptive options for the person, taking into account their previous experiences with pregnancy and childbirth. It can also help in evaluating the effectiveness of their past contraceptive methods and guide the selection of appropriate contraceptive counseling and options.
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