Nokea
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: Performing Leopold maneuvers helps the nurse determine the fetal position and presentation, which is essential for accurate placement of the external transducer.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
The correct actions to take are to place newborn skin to skin on birthing parent's chest and encourage breastfeeding, as these promote bonding and breastfeeding, crucial for newborn well-being. The potential condition the client is most likely experiencing is Cold stress, indicated by the need for phototherapy. The parameters to monitor are Temperature (to track for hypothermia due to cold stress) and Bilirubin level (to assess for jaundice, common in newborns with cold stress).
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: D
Rationale: Eliminating dairy products may help reduce nausea and vomiting in clients with hyperemesis gravidarum, as dairy can sometimes exacerbate these symptoms.
A nurse is making an initial postpartum home visit. Which of the following client statements should the nurse identity as a manifestation of Increased risk for child abuse?
- A. I want to meet other parents to see if they are going through the same things.
- B. I try to respond to the baby quickly so she doesn't cry very long.
- C. I think the baby should be sleeping through the night by now.
- D. I have several friends who come by to help out with the baby.
Correct Answer: C
Rationale: Expecting a newborn to sleep through the night is unrealistic and may indicate frustration or lack of understanding, which are risk factors for child abuse. Other statements reflect normal parental concerns or support systems.
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.
Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.
- A. Monitor blood pressure.
- B. Initiate contact precautions.
- C. Prepare for amniocentesis .
- D. Apply internal fecal monitor.
- E. Decrease lighting in the client's room
- F. Check urinary output.
- G. Encourage bed rest.
Correct Answer: A,C,G
Rationale: Reposition the client (Trendelenburg or knee-chest)