Nokea
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Other signs may include irritability and tremors.
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A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct Answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention.
A nurse is caring for a client who is at 38 weeks of gestation and is experiencing continuous abdominal pain and vaginal bleeding. The client has a history of cocaine use. The nurse should identify that the client is likely experiencing which of the following complications?
- A. Abruptio placentae
- B. Hydatidiform mole
- C. Preterm labor
- D. Placenta previa
Correct Answer: A
Rationale: Continuous abdominal pain and vaginal bleeding in a client with a history of cocaine use suggest abruptio placentae, where the placenta detaches from the uterus prematurely, posing serious risks to both mother and fetus.
A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct Answer: A
Rationale: Contractions that are too frequent or prolonged can lead to uterine hyperstimulation, which can compromise fetal oxygenation. The nurse should stop the oxytocin infusion to reduce contraction frequency and intensity.
A nurse is reviewing a client's medical record and notes that the client is taking tamoxifen. The nurse should identify that tamoxifen is used to treat which of the following conditions?
- A. Non-Hodgkin's lymphoma
- B. Endometriosis
- C. Breast cancer
- D. Polycystic ovary syndrome
Correct Answer: C
Rationale: Tamoxifen is an anti-estrogen medication primarily used to treat hormone receptor-positive breast cancer. It works by blocking estrogen receptors in breast tissue, slowing the growth of tumors that require estrogen to grow.
A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?
- A. We will place the baby on its back to sleep
- B. We will give the baby a pacifier at bedtime
- C. We will keep the baby's crib free of blankets and toys
- D. We will leave the baby's diaper off to prevent diaper rash
Correct Answer: D
Rationale: Leaving a baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash.