Nokea
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Dyspnea
- B. Headaches
- C. Nervousness
- D. Tremors
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.
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An 8-pound 15-ounce baby born at 35 weeks’ gestation would be described using which terminology? Select all that apply.
- A. Small for gestational age
- B. Term
- C. Preterm
- D. Average for gestational age
- E. Post term
Correct Answer: C,D
Rationale: The correct answer is C and D. Choice C, "Preterm," is correct because a baby born at 35 weeks' gestation is considered preterm, as full term is typically around 39-40 weeks. Choice D, "Average for gestational age," is also correct because the baby's weight falls within the normal range for babies born at 35 weeks. Choice A, "Small for gestational age," is incorrect as the baby's weight is appropriate for its gestational age. Choice B, "Term," is incorrect because 35 weeks is considered preterm. Choice E, "Post term," is incorrect as it refers to a baby born after 42 weeks' gestation.
After assisting with a vaginal delivery, what would the nurse do to prevent heat loss via conduction in the newborn?
- A. Dry the newborn with a warm blanket.
- B. Close the doors to the delivery room.
- C. Wrap the newborn in a blanket.
- D. Place the newborn on a warm crib pad.
Correct Answer: D
Rationale: The correct answer is D: Place the newborn on a warm crib pad. This helps prevent heat loss via conduction by providing a warm surface for the newborn to rest on, minimizing direct contact with a colder surface. Drying the newborn with a warm blanket (choice A) can help prevent heat loss via evaporation, not conduction. Closing the doors to the delivery room (choice B) may help maintain room temperature but does not directly prevent heat loss via conduction. Wrapping the newborn in a blanket (choice C) helps prevent heat loss via radiation, not conduction.
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse?
- A. You can push the baby to the room in a wheeled bassinet.
- B. If you show me your photo identification, you can take the infant.
- C. Have the mother ring, and I will take the baby to the room.
- D. You may carry your grandchild to the room.
Correct Answer: C
Rationale: The correct response is C: Have the mother ring, and I will take the baby to the room. This is the appropriate response because it ensures the safety and security of the newborn by confirming the mother's approval before allowing the grandmother to take the baby to the room. This step is crucial to prevent any unauthorized individuals from taking the baby without the mother's consent.
Choice A is incorrect because pushing the baby to the room in a wheeled bassinet may not involve verifying the mother's consent. Choice B is incorrect as asking for photo identification does not confirm the mother's approval. Choice D is incorrect as it assumes the grandmother can carry the baby without checking with the mother first.
In summary, choice C is the correct response as it prioritizes the safety and well-being of the newborn by ensuring the mother's consent is obtained before allowing the grandmother to take the baby to the room.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?
- A. Turning on the apnea#nbsp;apnea and cardiorespiratory monitor.
- B. Connecting the resuscitation bag to oxygen.
- C. Setting up the radiant warmer control temperature at 36.4°C (97.5°F).
- D. Preparing for the insertion of an intravenous (IV) line with D5W.
Correct Answer: B
Rationale: The correct answer is B: Connecting the resuscitation bag to oxygen. This intervention is the priority because the infant has low Apgar scores, indicating poor oxygenation and respiratory effort. Providing oxygen through the resuscitation bag will help improve oxygenation and support the infant's breathing, which is crucial in the immediate postnatal period.
Turning on the apnea and cardiorespiratory monitor (Choice A) may be important for continuous monitoring but addressing the oxygenation issue takes precedence. Setting up the radiant warmer control temperature (Choice C) is important for maintaining the infant's body temperature but not the immediate priority. Preparing for IV insertion with D5W (Choice D) is not necessary at this moment as the priority is to address the respiratory distress.