Nokea
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is primarily spread through direct contact with infected individuals or contaminated surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of MRSA to others. Droplet precautions (choice A) are used for diseases transmitted via respiratory droplets, such as influenza. Protective environment (choice C) is used for immunocompromised clients to protect them from environmental pathogens. Airborne precautions (choice D) are for diseases transmitted via small droplet nuclei, like tuberculosis. No other choices are applicable for MRSA.
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Which of the following is a potential barrier to evidence-based practice in maternal and newborn healthcare?
- A. Lack of access to up-to-date research
- B. Resistance to change
- C. Limited resources
- D. All of the above
Correct Answer: D
Rationale: All the options listed (lack of access to research resistance to change and limited resources) are common barriers to implementing evidence-based practice in healthcare settings. These factors can hinder the adoption of new practices and the improvement of care quality.
Which of the following is a professional standard for nursing practice in maternal and newborn healthcare?
- A. Safety and quality improvement
- B. Patient-centered care
- C. Leadership
- D. All of the above
Correct Answer: D
Rationale: All of the above are professional standards for nursing practice. Safety and quality improvement ensure high standards of care, patient-centered care focuses on individual needs, and leadership promotes effective teamwork and advocacy.
Complete the following sentence by using the list of options. Based on the client findings, the nurse should first admister-----------------and then prepare to administer-----------------------
- A. calcium gluconate
- B. hydralazine
- C. nifedipine
Correct Answer: B,A
Rationale: Rationale:
First administer hydralazine ✅
The client is experiencing severe hypertension (BP 170/112 mm Hg at 1400), which indicates preeclampsia with severe features.
Hydralazine is a fast-acting antihypertensive that helps lower blood pressure and reduce the risk of stroke, placental abruption, or fetal compromise.
Then prepare to administer calcium gluconate ✅
If the client is receiving magnesium sulfate for seizure prevention (common in severe preeclampsia), calcium gluconate is the antidote in case of magnesium toxicity (which can cause respiratory depression or cardiac arrest).
The nurse should have calcium gluconate readily available in case of toxicity signs like loss of deep tendon reflexes, respiratory depression, or cardiac arrhythmias.
Notify the provider 🚨
The severely elevated BP (170/112 mm Hg) and potential risk for eclampsia (seizures) require immediate provider notification for further management.
A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?
- A. Administer naloxone to the newborn.
- B. Swaddle the newborn with his legs extended.
- C. Maintain eye contact with the newborn during feedings
- D. Minimize noise in the newborn's environment.
Correct Answer: D
Rationale: Minimizing noise in the newborn's environment helps reduce overstimulation, which can exacerbate symptoms of neonatal abstinence syndrome. Naloxone is not used for this condition, and swaddling with legs extended is incorrect as it should be snug to provide comfort.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. During a nonstress test, the client is monitored for fetal heart rate accelerations in response to fetal movement. Instructing the client to press the button each time fetal movement is detected helps correlate fetal heart rate changes with fetal activity. This is crucial in assessing the well-being of the fetus.
A, B, and C are incorrect choices because maintaining the client NPO, placing the client in a supine position, and instructing the client to massage the abdomen are not relevant or necessary for a nonstress test. Option D is the best choice as it directly assists in monitoring fetal well-being during the test.