Nokea
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to inadequate energy supply to the respiratory muscles, resulting in respiratory distress. Hypertonia (A) is not a typical manifestation of hypoglycemia in newborns. Increased feeding (B) is a common response to hunger but not a direct indication of hypoglycemia. Hyperthermia (C) is not a typical sign of hypoglycemia. In summary, respiratory distress is a key clinical manifestation of hypoglycemia in late preterm newborns, making it the correct choice.
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Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
Which stage of labor is characterized by the period between full cervical dilation and delivery of the fetus?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: B
Rationale: The second stage of labor begins with full cervical dilation and ends with the delivery of the fetus.
A nurse is providing teaching about increasing dietary fiber to an antepartum client who reports constipation. Which of the following food selections has the highest fiber content per cup?
- A. Oatmeal
- B. Cabbage
- C. Asparagus
- D. Lentils
Correct Answer: D
Rationale: The correct answer is D: Lentils. Lentils have the highest fiber content per cup compared to the other options. Lentils contain around 15.6 grams of fiber per cup, making them an excellent choice to alleviate constipation. Oatmeal, cabbage, and asparagus have lower fiber content per cup compared to lentils. Oatmeal contains around 4 grams of fiber per cup, cabbage has about 2.2 grams, and asparagus has approximately 2.8 grams. Therefore, lentils are the best choice for increasing fiber intake to help with constipation during pregnancy.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale:
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: A rectal suppository like bisacodyl is appropriate for relieving constipation in a postpartum client with a perineal laceration, as it avoids straining. Loperamide is an antidiarrheal and not indicated here.