Nokea
A neonate is admitted to the neonatal intensive care unit for observation with a diagnosis of probable meconium aspiration syndrome (MAS). The neonate weighs10 lb, 4 oz (4,650 g) and is at 41 weeks' gestation. Which of the following nursing diagnoses would be the priority for this neonate?
- A. Impaired skin integrity related to post-term status.
- B. Imbalanced nutrition: More than body requirements related to large size.
- C. Risk for impaired parent-infant-child attachment related to transfer to the intensive care unit.
- D. Impaired gas exchange related to the effects of respiratory distress.
Correct Answer: D
Rationale: Impaired gas exchange is the priority due to the respiratory distress associated with meconium aspiration syndrome.
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A nurse is discussing sterilization with a male client. Which of the following statements by the nurse is accurate?
- A. A vasectomy is effective immediately.
- B. A vasectomy requires a follow-up sperm count to confirm sterility.
- C. A vasectomy prevents testosterone production.
- D. A vasectomy is reversible in all cases.
Correct Answer: B
Rationale: A vasectomy requires a follow-up sperm count to confirm sterility, as sperm may remain in the vas deferens initially. It is not effective immediately, does not affect testosterone production, and reversal is not always successful.
When developing a teaching plan for a primigravid client with insulin-dependent diabetes about monitoring blood glucose control and insulin dosages at home, which of the following would the nurse expect to include as a desired target range for blood glucose levels?
- A. 40 to 60 mg/dL between 2:00 and 4:00 p.m.
- B. 60 to 100 mg/dL before meals and bedtime snacks.
- C. 110 to 140 mg/dL before meals and bedtime snacks.
- D. 140 to 160 mg/dL 1 hour after meals.
Correct Answer: B
Rationale: Target range before meals and bedtime snacks is 60-100 mg/dL.
A primiparous client who delivered a viable neonate 8 hours ago tells the nurse that she gained 26 lb during pregnancy and asks how long it will take to return to her normal prepregnant weight. The nurse should tell the client that the usual time frame for returning to prepregnant weight is:
- A. 4 weeks.
- B. 6 weeks.
- C. 8 weeks.
- D. 12 weeks.
Correct Answer: D
Rationale: Returning to prepregnant weight typically takes about 12 weeks with proper diet and exercise.
A newborn is diagnosed with fetal alcohol syndrome. The nurse is teaching this mother what to expect when she goes home with her baby. The nurse determines the mother needs further instruction when she says which of the following?
- A. The way my baby's face looks now will stay that way.'
- B. My baby may be irritable as a newborn.'
- C. I may need some help coping with my newborn.'
- D. My baby will be fine soon after we are home.'
Correct Answer: D
Rationale: FAS is a lifelong condition, and the neonate will not be 'fine' soon after going home, indicating a need for further instruction.
A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states the adverse effects include which of the following?
- A. Epistaxis.
- B. Bleeding gums.
- C. Slow pulse.
- D. Petechiae.
Correct Answer: C
Rationale: Slow pulse is not a typical adverse effect of heparin; bleeding symptoms like epistaxis, bleeding gums, and petechiae are expected.