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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 an 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 action is important to ensure proper follow-up care, contact tracing, and prevention of HIV transmission. Administering penicillin G (A) is not indicated for HIV, scheduling an annual pelvic exam (B) is routine and not specific to the client's HIV status, and starting medication post-delivery (C) delays necessary treatment.
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A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: Oligohydramnios, or low amniotic fluid, is an indication for electronic fetal monitoring as it can be associated with fetal distress and other complications.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because obtaining informed consent ensures that the client understands the risks, benefits, and alternatives of the procedure. It also respects the client's autonomy and right to make decisions about their care.
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for dinoprostone insert.
C: Instructing the client to avoid urinary elimination is not necessary and could potentially harm the client by causing urinary retention.
Summary: The correct action is to ensure informed consent is obtained, as it is a fundamental ethical and legal requirement in healthcare.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn indicate respiratory distress and can be a sign of underlying respiratory issues such as respiratory distress syndrome. The nurse should report this finding to the provider immediately for further evaluation and intervention to ensure the newborn's respiratory status is stable. Acrocyanosis (choice B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (choice C) can be a normal variation in newborn skull anatomy. The head circumference of 33 cm (13 in) (choice D) is within the normal range for a newborn and would not require immediate reporting.
Which of the following is a potential complication of neonatal hypothermia?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Jaundice
- D. All of the above
Correct Answer: D
Rationale: All of the above are potential complications of neonatal hypothermia. Hypothermia can lead to hypoglycemia, respiratory distress, and jaundice due to the infant's inability to regulate body temperature.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C: "The car seat should be positioned in the car at a 45-degree angle." This is correct because newborns and premature babies (delivered at 38 weeks) have less muscle tone and are at risk of airway compromise if the head falls forward in the car seat. Placing the car seat at a 45-degree angle helps keep the baby's airway open and prevents slumping.
A: "I can use a sleep sack to keep my baby warm in the car seat." - This is incorrect as bulky clothing or blankets should not be used in the car seat as they can compress in a crash and create a loose harness fit.
B: "My baby will need a car seat challenge test before discharge." - This is incorrect as car seat challenge tests are usually done for premature infants born before 37 weeks.
D: "When my baby is 1 year old, I can turn their car seat facing forward." - This is incorrect as rear