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A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: D
Rationale: The correct answer is D: Vomiting. Newborns exposed to SSRIs in utero may experience withdrawal symptoms due to drug discontinuation at birth. Vomiting is a common withdrawal manifestation in newborns due to the sudden absence of the drug. Large for gestational age (choice A) is not typically associated with SSRI withdrawal. Hyperglycemia (choice B) and bradypnea (choice C) are not typical withdrawal symptoms of SSRIs. Therefore, the nurse should identify vomiting as an indication of withdrawal from an SSRI in the newborn.
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A nurse in an antepartum clinic is providing weeks of gestation. Upon reviewing the following findings should the nurse report to the provider? (Click on the 'Exhibit' button for additional information about the client. There are three tabs that contain separate categories of data.)
- A. 1-hr glucose tolerance test
- B. Hematocrit
- C. Fundal height measurement
- D. Fetal heart rate (FHR)
Correct Answer: D
Rationale: The correct answer is D: Fetal heart rate (FHR). The nurse should report any abnormal findings related to fetal well-being to the provider. Monitoring the FHR is crucial to assess the baby's status and can indicate potential issues such as fetal distress. In this scenario, if the FHR is abnormal (e.g., too high or too low), it could signal a problem that needs immediate attention.
A: 1-hr glucose tolerance test - This is typically done to screen for gestational diabetes and is not directly related to fetal well-being.
B: Hematocrit - This measures the volume percentage of red blood cells in blood and is more related to maternal health.
C: Fundal height measurement - This assesses fetal growth and position, but abnormal findings may not require immediate provider notification unless significant deviations are noted.
In summary, the other choices are not as time-sensitive or directly indicative of fetal distress as the FHR, making D the correct answer in this context.
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 respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps create a soothing and comforting environment for the baby. This position mimics the closeness and security of being held, promoting bonding and emotional connection between the guardian and the newborn. It also aids in digestion and reduces the risk of choking. Placing the newborn in the crib in a prone position (B) is unsafe as it increases the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may introduce unnecessary calories and disrupt feeding patterns. Preparing a bottle with rice cereal (D) can pose a choking hazard and is not recommended for newborns.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client's condition to the local health Department.
Correct Answer: D
Rationale: The correct answer is D: Report the client's condition to the local health department. This is important to ensure proper monitoring, follow-up, and infection control measures. Reporting is necessary for contact tracing, prevention of transmission, and accessing appropriate support services. Administering penicillin G (A) is not indicated for HIV; the client needs antiretroviral therapy. Scheduling annual pelvic exams (B) is important for general health but not specific to HIV care. Waiting until after delivery to start HIV medication (C) is not recommended as timely treatment is crucial.
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat foods that taste good instead of balancing my meals.
- B. I will avoid having a snack before I go to bed each night.
- C. I will have a cup of hot tea with each meal.
- D. I will eliminate products that contain dairy from my diet.
Correct Answer: A
Rationale: The correct answer is A. By stating she will eat foods that taste good instead of balancing meals, the client demonstrates understanding of the need to prioritize eating to manage hyperemesis gravidarum. This choice indicates she recognizes the importance of maintaining adequate nutrition despite food aversions. Choice B is incorrect as avoiding bedtime snacks may worsen nausea. Choice C is incorrect as caffeine in tea can exacerbate nausea. Choice D is incorrect as dairy products are important for calcium and protein intake during pregnancy.