Nokea
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond?
- A. Advise the mother to wait at least another month before starting any solid foods.
- B. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal.
- C. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
- D. Encourage the mother to schedule a developmental assessment of the infant.
Correct Answer: C
Rationale: At 6 months, infants are generally ready to start eating iron-fortified cereals as their iron stores begin to deplete. Introducing iron-fortified cereals at this age helps meet the infant's nutritional needs, particularly for iron, which becomes deficient as the infant's iron reserves diminish. It is a safe and appropriate first food to introduce to infants around 6 months of age, along with continued breastfeeding or formula feeding.
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A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 mL of D5W. How many milliliters of the solution should the nurse administer?
- A. 45
- B. 15 mL
- C. 4
- D. 13
Correct Answer: D
Rationale: To calculate the amount of terbutaline to administer, first convert the dose to the same unit. 250 mcg = 0.25 mg. Next, set up a proportion: 20 mg is to 1000 mL as 0.25 mg is to X mL. Cross multiply and solve for X: 20 X = 0.25 1000. X = (0.25 1000) / 20 = 12.5 mL. Therefore, the nurse should administer 13 mL of the solution.
The healthcare provider is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?
- A. Positive Babinski reflex.
- B. Flexion of all four extremities.
- C. Heart rate of 220 beats/min.
- D. Cries vigorously when stimulated.
Correct Answer: D
Rationale: A vigorous cry upon stimulation indicates that the newborn has good respiratory effort and is transitioning well to life outside the womb. It shows that the infant's airways are clear, and they are able to establish effective breathing, a crucial aspect of transitioning successfully to extrauterine life.
The client is admitted in active labor with a cervix that is 3 cm dilated, 50% effaced, and the presenting part at 0 station. An hour later, the client expresses the need to go to the bathroom. Which action should the nurse implement first?
- A. Palpate the client's bladder.
- B. Check the pH of the vaginal fluid.
- C. Review the fetal heart rate pattern.
- D. Determine cervical dilation.
Correct Answer: D
Rationale: The nurse should prioritize determining cervical dilation as it helps in assessing the progress of labor and ensures it is safe for the client to move. Changes in cervical dilation may indicate the advancement of labor, warranting appropriate interventions or restrictions on movement to prevent complications.
A newborn with a yellow abdomen and chest is being assessed. What should the nurse do?
- A. Assess bilirubin level.
- B. Administer phototherapy.
- C. Encourage feeding to help reduce bilirubin levels.
- D. Perform a bilirubin test every hour.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with no prenatal care arrives at the labor unit screaming, 'The baby is coming!' The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the LPN/LVN to obtain?
- A. Gravidity and parity.
- B. Time and amount of last oral intake.
- C. Date of last normal menstrual period.
- D. Frequency and intensity of contractions.
Correct Answer: C
Rationale: Obtaining the date of the last normal menstrual period is crucial in estimating the gestational age of the fetus. This information helps in determining the progression of labor and the management of delivery. It also assists healthcare providers in assessing the overall health of the mother and the fetus.