Nokea
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: C, D
Rationale: The correct manifestations of SSRI withdrawal in a newborn are bradypnea (C) and vomiting (D). SSRI use during pregnancy can lead to neonatal withdrawal symptoms due to drug exposure in utero. Bradypnea is a common withdrawal symptom characterized by slow breathing rate in newborns. Vomiting is another withdrawal symptom that can occur in newborns exposed to SSRIs. Large for gestational age (A) and hyperglycemia (B) are not typical manifestations of SSRI withdrawal. Therefore, the nurse should focus on monitoring for bradypnea and vomiting as signs of SSRI withdrawal in the newborn.
You may also like to solve these questions
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Staff wearing photo ID badges ensures proper identification for security.
2. Visual verification protects against unauthorized individuals caring for the baby.
3. ID badges indicate staff members have been vetted and authorized to care for newborns.
4. Promotes safety by ensuring only qualified individuals handle the baby.
Summary:
A: Carrying the baby to the nursery poses security risks and disrupts mother-infant bonding.
B: Documenting visitor relationships is important but does not directly address newborn security.
C: Co-sleeping with the baby in the hospital increases the risk of accidental suffocation.
D: Correct choice, as it directly addresses security and safety measures for the newborn.
E:
F:
G:
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: A displaced uterus to the right above the umbilicus may indicate a full bladder. Assisting the client to empty their bladder helps the uterus return to its proper position and prevents complications like postpartum hemorrhage.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn baby, aiding in the grieving process and facilitating closure. It is important for the client to have something to remember their child by, as it validates the existence of the baby and acknowledges the client's loss. It also promotes a sense of connection and remembrance. Providing photos can be a compassionate gesture that supports the client emotionally during this difficult time.
Choice A is incorrect because limiting the time the fetus is in the room may not consider the client's emotional needs. Choice C is incorrect as it may add unnecessary stress to the client. Choice D is incorrect as there is no legal requirement to name a stillborn fetus.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. Late decelerations in FHR during oxytocin infusion indicate uteroplacental insufficiency. Administering oxygen helps improve oxygenation to the fetus, potentially alleviating the late decelerations. This action addresses the underlying cause and supports fetal oxygenation. In contrast, option A may increase intrauterine pressure, worsening fetal distress. Option C (supine position) can further compromise placental perfusion. Option D (amnioinfusion) is used for variable decelerations, not late decelerations.
A nurse is caring for a client who is in labor and notes that the umbilical cord is prolapsed. Which of the following actions should the nurse take?
- A. Evaluate uterine tone.
- B. Loosely wrap the cord with petroleum gauze.
- C. Apply fundal pressure.
- D. Place the client in Trendelenburg position
Correct Answer: D
Rationale: Placing the client in the Trendelenburg position helps reduce pressure on the prolapsed cord, preventing fetal distress. Other actions like applying fundal pressure or wrapping the cord are not appropriate.