Nokea
A neonate at 37 weeks' gestation is delivered by cesarean delivery because of placenta previa. Which of the following would the circulating nurse do first as soon as the neonate is delivered?
- A. Stimulate the neonate to cry vigorously.
- B. Aspirate mucus from the mouth with a bulb syringe.
- C. Begin resuscitation procedures with a bag and mask.
- D. Hold the neonate upright for the mother to view.
Correct Answer: B
Rationale: Aspirating mucus from the mouth with a bulb syringe clears the airway, which is the first priority to ensure breathing.
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A nurse is discussing emergency contraception with a client. Which of the following statements by the nurse is accurate?
- A. Emergency contraception is most effective when taken within 72 hours of unprotected intercourse.
- B. Emergency contraception requires a prescription for all women.
- C. Emergency contraception is 100% effective in preventing pregnancy.
- D. Emergency contraception can be used as a regular method of birth control.
Correct Answer: A
Rationale: Emergency contraception, like Plan B, is most effective within 72 hours of unprotected intercourse. It is available over-the-counter for those 17 and older, is not 100% effective, and is not suitable for regular use due to lower efficacy and side effects.
The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 grams (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 1,350 grams (7 lb, 14 oz).Which of the following instructions should the nurse give to the mother?
- A. Continue feeding every 3 to 4 hours since the weight loss is normal.
- B. Contact the physician if the weight loss continues over the next few days.
- C. Switch to a soy-based formula because the current one seems inadequate.
- D. Change to a higher-calorie formula to prevent further weight loss.
Correct Answer: A
Rationale: The weight loss from 3,912 g to 3,550 g (7 lb, 14 oz) is approximately 9%, which is within the normal range of up to 10% for newborns in the first few days. Continuing regular feedings is appropriate.
A primigravid client in active labor has had no anesthesia. The client's cervix is 7 cm dilated, and she is starting to feel considerable discomfort during the first 10 cm to the client's sacral client is a left side-lying position. The nurse should encourage which of the following?
- A. Rapid, shallow chest breathing.
- B. Deep chest breathing.
- C. Rapid pant-blow breathing.
- D. Slow abdominal breathing.
Correct Answer: D
Rationale: Slow abdominal breathing promotes relaxation and oxygenation, helping manage discomfort in active labor without anesthesia. Rapid or shallow breathing may lead to hyperventilation, and deep chest breathing is less effective for pain control.
As the nurse enters the room of a newly admitted primigravid client diagnosed with severe preeclampsia, the client begins to experience a seizure. The nurse should do which in order of priority from first to last?
- A. Call for immediate assistance.
- B. Turn the client to her side.
- C. Note the time when the seizure began.
- D. Maintain airway.
Correct Answer: A,D,B,C
Rationale: Call for help, ensure the airway is clear, turn the client to prevent aspiration, and document the seizure duration.
After teaching the parents of a neonate born with a cleft lip and cleft palate about appropriate feeding techniques, the nurse determines that the mother needs further instruction when the mother says which of the following?
- A. I should clean her mouth with soapy water after feeding.'
- B. I should feed her in an upright position.'
- C. I need to remember to burp her often.'
- D. I may need to use a special nipple for feeding.'
Correct Answer: A
Rationale: Cleaning the mouth with soapy water is inappropriate and could irritate the cleft, indicating a need for further instruction.