Nokea
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1° C (96.9° F)
- D. Excessive sleeping
Correct Answer: B
Rationale: Moderate tremors of the extremities are a common sign of opioid withdrawal in newborns. Other signs may include irritability, feeding difficulties, and gastrointestinal disturbances.
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A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest thrusts
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct Answer: C
Rationale: If routine suctioning with a bulb syringe is ineffective, the next step is to use mechanical suction. This ensures that any obstruction in the airway is cleared. If the newborn's condition does not improve, chest compressions or further interventions may be needed.
A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct Answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion
- B. Administer oxygen at 10 L/min via nonrebreather face mask
- C. Discontinue the infusion of oxytocin
- D. Place the client in a left lateral position
Correct Answer: C
Rationale: The first action should be to discontinue the infusion of oxytocin, as it can contribute to uterine hyperstimulation and fetal distress. This allows for immediate assessment and management of the fetal heart rate.
Which of the following would increase a client's risk of ovarian cancer?
- A. History of fibroids
- B. Early menopause
- C. Endometriosis
- D. Polycystic ovary syndrome
Correct Answer: C
Rationale: Endometriosis is associated with an increased risk of developing ovarian cancer due to chronic inflammation and hormonal imbalances. The exact cause is not fully understood, but women with endometriosis should be monitored closely.
A nurse is caring for a newborn with hyperbilirubinemia. Which of the following interventions should be taken during phototherapy?
- A. Maintain an eye mask over the newborn's eyes
- B. Feed the newborn every hour
- C. Monitor the newborn's temperature
- D. Administer vitamin K
Correct Answer: A
Rationale: Phototherapy is used to reduce bilirubin levels in newborns with jaundice. However, the intense light can cause damage to the newborn's corneas and retinas. The use of an eye mask protects the infant's eyes while allowing the therapy to proceed. Regular monitoring of the newborn's temperature and hydration status is also important, but the eye mask is a key protective measure.