Nokea
A nurse is assessing a client during her first prenatal visit the client reports March 20th us her last menstrual.. Use Niagele9s rule to calculate the estimated date of delivery. Use the mmdd format with four numerals and no spaces or punctuation.
- A. 05/11
- B. 5/4
- C. 5/12
- D. 04/27
Correct Answer: A
Rationale: The correct answer is A: 05/11. Using Naegele's rule, add 7 days to the first day of the last menstrual period (March 20), subtract 3 months, and add 1 year. March 20 + 7 days = March 27. Subtracting 3 months gives us December 27. Adding 1 year brings us to December 27 of the following year. However, since we are looking for the estimated date of delivery, we add 7 days to adjust for the 7 days we added at the beginning, which gives us May 4. Therefore, the estimated date of delivery would be May 11. Choice B (5/4) is incorrect because it does not account for the 7-day adjustment. Choice C (5/12) is incorrect as it adds 7 days twice. Choice D (04/27) is incorrect as it doesn't correctly follow Naegele's rule.
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A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5day old male newborn at home. Which of the following statements should the nurse make to the client?
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important as decreased urine output can indicate dehydration in a newborn, which is a serious concern. It is crucial to monitor the baby's hydration status closely in the early days of life.
A: Retracting the foreskin to clean the baby's penis is not recommended as it can cause harm and is not necessary at this age.
B: Using triple antibiotic ointment on the umbilical cord is not recommended as it can delay the natural healing process.
C: Swaddling the baby tightly with legs extended is not recommended as it can increase the risk of hip dysplasia.
In summary, the other choices are incorrect because they may cause harm or are not recommended practices for caring for a newborn.
A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 Seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: 6 contractions in 10 minutes. This indicates hyperstimulation of the uterus, putting the fetus at risk. Discontinuing oxytocin is necessary to prevent uterine tachysystole. Contractions lasting 60 seconds (choice A) are normal. Non-repetitive early decelerations (choice B) are benign. Moderate variability of the fetal heart rate (choice D) is a reassuring sign of fetal well-being.
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics
- B. Cleanse the site with Povidone iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial in preventing infection in a newborn with myelomeningocele where the spinal cord is exposed. Infection can lead to serious complications. Administering broad-spectrum antibiotics helps to reduce the risk of infection. Cleansing the site with Povidone iodine (choice B) is important, but antibiotics are necessary for prophylaxis. Monitoring rectal temperature (choice C) is not directly related to preventing infection. Surgical closure (choice D) after 72 hours is important, but antibiotics are essential immediately post-birth to prevent infection.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous from pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because applying steady pressure with a tennis ball to the lower back can help relieve lower back pain during labor. This technique targets the sacral area, which can alleviate discomfort and provide comfort. Choice A is incorrect as upward pressure on the lower abdomen may not be effective for pain relief. Choice B is incorrect as applying continuous pressure between the thumb and index finger is not related to counter pressure for labor pain. Choice C is incorrect as pressure on the top of the uterus during contractions is not a recommended technique.
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make?
- A. Avoid Eating snacks before bedtime
- B. Eat high-fat snack before getting out of bed
- C. Drink additional liquids with each meal
- D. Consume food served at cool temperatures
Correct Answer: D
Rationale: The correct answer is D: Consume food served at cool temperatures. This recommendation is based on the fact that pregnant women experiencing nausea and vomiting (commonly known as morning sickness) may find relief by consuming cold or cool foods, as they are less likely to trigger nausea compared to hot or warm foods. Cold foods also tend to have less of a strong smell, which can help reduce nausea. Avoiding snacks before bedtime (choice A) may not necessarily alleviate nausea in the morning. Eating high-fat snacks before getting out of bed (choice B) may worsen nausea. Drinking additional liquids with each meal (choice C) may not address the underlying cause of nausea and could potentially make it worse.