Nokea
A multigravid client at 34 weeks' gestation with premature rupture of the membranes tests positive for group B streptococcus. The client is having contractions every 4 to 6 minutes. Her vital signs are as follows: blood pressure, 120/80 mm Hg; temperature, 100° F(37.8° C); pulse, 100 bpm; respirations, 18 breaths/minute. Which of the following would the nurse expect the physician to order?
- A. Intravenous penicillin.
- B. Intravenous gentamicin sulfate(Garamycin).
- C. Intramuscular betamethasone(Celestone).
- D. Intramuscular cefaclor(Ceclor).
Correct Answer: A
Rationale: Penicillin is used to treat group B streptococcus.
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An infant born premature at 34 weeks is receiving gavage feedings. The client holding her infant asks why the nurse places a pacifier in the infant's mouth during these feedings. The nurse replies that the pacifier helps in what ways? Select all that apply.
- A. Teaches the infant to suck and swallow.
- B. Provides oral stimulation.
- C. Keeps oral mucus membranes moist while the tube is in place.
- D. Reminds the infant how to suck.
- E. Stimulates secretions that help gastric emptying.
Correct Answer: B,D
Rationale: The pacifier provides oral stimulation and reminds the infant how to suck, promoting oral motor development.
A 30-year-old multigravid client at 8 weeks' gestation has a history of insulin-dependent diabetes since age 20. When explaining about the importance of blood glucose control during pregnancy, the nurse should tell the client that which of the following will occur regarding the client's insulin needs during the first trimester?
- A. They will increase.
- B. They will decrease.
- C. They will remain constant.
- D. They will be unpredictable.
Correct Answer: B
Rationale: Insulin needs typically decrease in the first trimester due to increased insulin sensitivity.
At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin; which of these findings warrants further assessment?
- A. Frequent hiccups.
- B. Loose, watery stool in diaper.
- C. Pink papular vesicles on the face.
- D. Dry, peeling skin.
Correct Answer: B
Rationale: Loose, watery stool may indicate diarrhea, which requires further assessment to rule out infection or malabsorption.
A multigravid client is admitted at 4-cm dilation and requesting pain medication. The nurse gives the client Nubain 15 mg and Phenergan 25 mg slow I.V. push. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first:
- A. Have naloxone hydrochloride (Narcan) available in the delivery room.
- B. Perform a vaginal examination to determine dilation, effacement, and station.
- C. Prepare for delivery.
- D. Document the client's relief due to pain medication.
Correct Answer: B
Rationale: A sudden urge to have a bowel movement in labor often indicates rapid progression to full dilation or fetal descent. A vaginal examination confirms dilation and station to guide next steps (e.g., preparing for delivery). Naloxone, preparation, or documentation are premature without assessment.
The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unlicensed nursing personnel?
- A. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin.
- B. A G4 P4 who is breast-feeding an 8 lb infant without difficulty.
- C. A G3 P3 postpartum client who is receiving Magnesium Sulfate and whose infant has a respiratory rate of 20.
- D. A G2 P2 who delivered vaginally 2 days ago with an infant having low blood glucose levels the first 24 hours post delivery.
Correct Answer: B
Rationale: The G4 P4 client with stable breastfeeding is appropriate for UAP delegation, as no complex medical needs are present.