Nokea
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: A urine output of 280 mL within 8 hours is low and may indicate dehydration, which is a concern in a client with hyperemesis gravidarum.
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What is the recommended method of administering hepatitis B vaccine to a newborn?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: A
Rationale: The correct answer is A: Intramuscular injection. Administering hepatitis B vaccine via intramuscular injection ensures proper absorption and immune response. Injecting into the muscle allows for efficient delivery to the bloodstream. Oral administration (B) is not effective as the vaccine may be degraded in the digestive system. Topical application (C) and subcutaneous injection (D) are not recommended for hepatitis B vaccine due to inadequate absorption and immune response.
The nurse is preparing the infant for phototherapy.For each nursing action, click to specify if the action is indicated or contraindicated for the newborn.
- A. Supplement feeding with sterile water.
- B. Dress in only a diaper.
- C. Cover newborn's eyes with a shield
- D. Apply lotion to skin every 4 Mr.
- E. Breastfeed every 2 to 3 hr.
Correct Answer:
Rationale: Increase IV fluids for better circulation
The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -------------------------- evidenced by --------------------------
- A. Pelvic inflammatory disease
- B. Ectopic pregnancy
- C. C-reactive protein
- D. Beta hCG level
- E. Urinalysis
Correct Answer:
Rationale:
Which hormone is responsible for triggering milk ejection during breastfeeding?
- A. Progesterone
- B. Estrogen
- C. Prolactin
- D. Oxytocin
Correct Answer: D
Rationale: The correct answer is D: Oxytocin. Oxytocin is responsible for triggering milk ejection during breastfeeding by causing the contraction of muscles around the milk-producing cells, facilitating the release of milk. Progesterone and estrogen are involved in preparing the body for pregnancy and maintaining the uterine lining, not milk ejection. Prolactin stimulates milk production but not milk ejection directly. Therefore, the correct choice is oxytocin as it specifically triggers the release of milk during breastfeeding.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+.
- B. Fundal height 14 cm.
- C. Blood pressure 142/94 mm Hg.
- D. FHR 152/min.
Correct Answer: D
Rationale: A fetal heart rate (FHR) of 152/min is within the normal range of 110 to 160 beats per minute for a fetus at 18 weeks of gestation.