Nokea
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: The correct answer is D: To facilitate bonding between the newborn and parent. Applying the ointment immediately after birth may interfere with the crucial bonding process between the newborn and the parent. It is important for the parent to have uninterrupted skin-to-skin contact and establish a strong emotional connection with the newborn during the first moments after birth. This bonding time is essential for the newborn's emotional well-being and can have long-lasting positive effects on their development. Delaying the instillation of the ointment allows for this important bonding process to occur naturally.
Choice A is incorrect because early identification of infection is crucial and should not be delayed. Choice B is unrelated to the instillation of ointment. Choice C is also unrelated, as the mode of delivery does not affect the timing of ointment instillation.
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A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Frequent vomiting with weight loss of 3 lb in 1 week
- B. Reports of mood swings
- C. Nosebleeds occurring approximately 3 times per week
- D. Increased vaginal discharge
Correct Answer: A
Rationale: The correct answer is A. Frequent vomiting with weight loss of 3 lb in 1 week is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and malnutrition, posing risks to both the mother and fetus. This requires immediate medical attention to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically alarming.
C: Nosebleeds are common in pregnancy due to increased blood volume and hormonal changes, and occurring three times per week is not unusual.
D: Increased vaginal discharge is a common symptom of early pregnancy due to hormonal changes and increased blood flow to the pelvic area, which is typically not concerning.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lay in a supine position throughout the test.
- C. You should not eat or drink for 2 hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: The correct answer is D because pressing the handheld button when feeling the baby move helps monitor fetal heart rate and movements during the test. This action allows healthcare providers to assess the baby's well-being. Choice A is incorrect as the test duration varies. Choice B is wrong as the client should lay on their left side, not supine, to prevent compression of the vena cava. Choice C is incorrect as eating and drinking are not restricted before the test.
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation of the cheeks
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. This finding may indicate a serious condition called preeclampsia, characterized by high blood pressure and protein in the urine, posing risks to both the mother and baby. Reporting this promptly allows for timely management and monitoring.
Incorrect choices:
B: Varicose veins in the calves are common in pregnancy due to increased blood volume and pressure on veins, usually not an urgent concern.
C: Nonpitting 1+ ankle edema is a mild swelling often seen in pregnancy, which is typically expected and not alarming at this stage.
D: Hyperpigmentation of the cheeks, known as melasma or "mask of pregnancy," is a common cosmetic change in pregnancy, not requiring immediate medical attention.
A nurse is preparing to administer an IM injection to a newborn. Which of the following sites should the nurse select?
- A. Vastus lateralis
- B. Dorsogluteal
- C. Deltoid
- D. Rectus femoris
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. For newborns, the vastus lateralis muscle is the preferred site for intramuscular injections due to its large muscle mass, minimal nerves and blood vessels, and reduced risk of hitting bone. It is located on the lateral aspect of the thigh and is easily accessible for injections. This site also allows for proper absorption of the medication. The other options are not ideal for newborns: B: Dorsogluteal is not recommended due to the risk of damaging the sciatic nerve, C: Deltoid is typically used for older children and adults, and D: Rectus femoris is not a common site for IM injections in newborns.
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. This action is essential during a nonstress test to monitor fetal heart rate and movement patterns. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, providing valuable information about the fetal well-being. Maintaining the client NPO (Option A) is not necessary for a nonstress test. Placing the client in a supine position (Option B) can decrease blood flow to the fetus. Instructing the client to massage the abdomen (Option C) may lead to inaccurate test results.