Nokea
A newborn with a cleft palate at 1 hour of life has a nursing diagnosis of Risk for Infection related to potential aspiration during feedings. Which of the following nursing actions would support the best feeding practice for this infant?
- A. Use an appropriate nipple and bottle set.
- B. Encourage the mother to breast-feed.
- C. Assess daily weights and wet diapers to monitor intake.
- D. Allow unlimited length of time for each feeding.
Correct Answer: A
Rationale: Using an appropriate nipple and bottle set designed for cleft palate infants minimizes aspiration risk during feedings.
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In which of the following maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior(LOA) position?
- A. Near the symphysis pubis.
- B. Two inches above the umbilicus.
- C. Below the umbilicus on the left side.
- D. At the level of the umbilicus.
Correct Answer: C
Rationale: The transducer should be placed below the umbilicus on the left side for LOA position.
A 16-year-old primigravid client, with a history of attending one prenatal visit, is admitted to the hospital in active labor at 37 weeks' gestation. Her cervix is 7 cm dilated with the presenting part at 0 station. She enters the labor unit appearing anxious and hyperventilating. Because of the hyperventilation, the nurse should assess the client for:
- A. Metabolic alkalosis.
- B. Metabolic acidosis.
- C. Respiratory alkalosis.
- D. Respiratory acidosis.
Correct Answer: C
Rationale: Hyperventilation causes excessive exhalation of carbon dioxide, leading to respiratory alkalosis (elevated blood pH). Metabolic imbalances are less likely, and respiratory acidosis occurs with hypoventilation.
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?
- A. 6 months.
- B. 12 months.
- C. 18 months.
- D. 24 months.
Correct Answer: B
Rationale: Waiting 12 months allows for monitoring for choriocarcinoma.
A woman who is Rh-negative has delivered an Rh-positive infant. The nurse explains to the client that she will receive RhoGAM. The nurse determines that the client understands the purpose of RhoGAM when she states:
- A. "RhoGAM will protect my next baby if it is Rh-negative."
- B. "RhoGAM will prevent antibody formation in my blood."
- C. "RhoGAM will be given to prevent German measles."
- D. "RhoGAM will be used to prevent bleeding in my newborn."
Correct Answer: B
Rationale: RhoGAM prevents maternal antibody formation against Rh-positive blood.
A viable male neonate delivered to a 28-year-old multiparous client by cesarean delivery because of placenta previa is diagnosed with respiratory distress syndrome. Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?
- A. Mother's development of placenta previa.
- B. Neonate delivered preterm.
- C. Mother receiving analgesia 4 hours before delivery.
- D. Neonate with sluggish respiratory efforts after delivery.
Correct Answer: B
Rationale: Preterm delivery is the primary risk factor for RDS due to immature lung development and insufficient surfactant production.