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 result from central nervous system irritability during withdrawal. Elevated norepinephrine levels lead to excessive stimulation, causing tremors and jitteriness.
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A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include?
- A. Nulliparity.
- B. History of breastfeeding.
- C. Use of postmenopausal estrogen.
- D. Previous use of oral contraceptives.
- E. History of breast cancer.
Correct Answer: A,C,E
Rationale: Nulliparity (A) increases ovarian cancer risk by prolonging ovulation periods. Postmenopausal estrogen (C) elevates risk by stimulating cell proliferation. History of breast cancer (E) correlates with increased risk due to shared genetic mutations like BRCA1/2.
A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression.
- B. Taking-in phase.
- C. Postpartum blues.
- D. Taking-hold phase.
Correct Answer: C
Rationale: Postpartum blues, characterized by mood swings, crying spells, and irritability, typically resolve within two weeks postpartum and are linked to hormonal changes.
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 8 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase their intake during the first trimester of pregnancy?
- A. Vitamin E.
- B. Protein.
- C. Fiber.
- D. Calcium.
Correct Answer: B
Rationale: Protein requirements increase to support fetal growth, placental development, and maternal tissue expansion. Pregnant clients need approximately 1.1 g/kg/day, compared to 0.8 g/kg/day for non-pregnant individuals.
Complete the following sentence using the lists of options: The nurse should [option] intramuscular ceftriaxone [purpose].
- A. The nurse should prescribe intramuscular ceftriaxone to decrease the risk of ophthalmia neonatorum in a newborn.
- B. The nurse should identify ceftriaxone as a suitable medication for bacterial infections.
- C. The nurse should use intramuscular ceftriaxone to treat gonorrhea effectively.
- D. The nurse should select intramuscular ceftriaxone for prophylaxis against postpartum infections.
Correct Answer: A
Rationale: Intramuscular ceftriaxone is effective in preventing ophthalmia neonatorum, caused by Neisseria gonorrhoeae. This bacterial prophylaxis inhibits cell wall synthesis, reducing infection transmission from mother to newborn.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin.
- B. Azithromycin.
- C. Ceftriaxone.
- D. Acyclovir.
Correct Answer: A
Rationale: Ampicillin is a first-line antibiotic effective against group B streptococcus B-hemolytic bacteria, preventing neonatal infection during labor. It targets the bacterial cell wall synthesis and is safe in pregnancy.