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A nurse is caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?
- A. Provide the newborn with 15 mL glucose water after each feeding.
- B. Turn the newborn every 4 hr.
- C. Apply hydrating lotion to the newborn’s skin prior to treatment.
- D. Close the newborn's eyes before applying eyepatches.
Correct Answer: D
Rationale: The correct answer is D: Close the newborn's eyes before applying eyepatches. This is important to protect the newborn's eyes from exposure to the bright light used in phototherapy, which can cause damage if the eyes are left open. Closing the eyes with eyepatches ensures that the light therapy is safely administered without harming the eyes.
A: Providing glucose water is not relevant to managing jaundice with phototherapy.
B: Turning the newborn every 4 hours is important for preventing pressure ulcers, but it is not directly related to phototherapy.
C: Applying hydrating lotion is not necessary before phototherapy and may interfere with the treatment.
E, F, G: Not provided.
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A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?
- A. Place the client in a supine position for 30 min following the first dose of anesthetic solution.
- B. Administer 1000 mL of dextrose 5% in water prior to the first dose of anesthetic solution
- C. Monitor the client’s blood pressure every 5 min following the first dose of anesthetic solution.
- D. Ensure the client has been NPO 4 hr prior to the placement of the epidural and the first dose of anesthetic solution.
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution. This is crucial because epidural anesthesia can cause hypotension, a common side effect. Monitoring the client's blood pressure closely allows for early detection of hypotension and prompt intervention to prevent potential complications like fetal distress. Placing the client in a supine position for 30 min (A) is incorrect as it can lead to hypotension; administering dextrose solution (B) is not necessary for epidural anesthesia; ensuring NPO status (D) is important for other procedures but not specifically for epidural anesthesia.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation
- B. Temperature
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.
A nurse is assessing a client who is 3 days postpartum. Which of the following findings should the nurse report to the provider?
- A. Cool, clammy skin
- B. Moderate lochia serosa
- C. Heart rate 89/min
- D. BP 120/70 mm Hg
Correct Answer: A
Rationale: The correct answer is A: Cool, clammy skin. This finding could indicate hypovolemic shock, a serious postpartum complication. The nurse should report this to the provider immediately for further evaluation and intervention to prevent deterioration. Moderate lochia serosa (B) is expected 3 days postpartum. Heart rate of 89/min (C) and BP of 120/70 mm Hg (D) are within normal range for a postpartum client and do not require immediate reporting.
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. This finding is concerning as it may indicate hyperemesis gravidarum, a severe form of morning sickness that can lead to dehydration and electrolyte imbalances, posing a risk to both the mother and fetus. The weight loss is significant and needs immediate attention from the provider to prevent complications.
B: Reports of mood swings are common in pregnancy due to hormonal changes and are not typically a cause for immediate concern.
C: Nosebleeds occurring approximately 3 times per week are often due to increased blood volume and hormone changes during pregnancy and are not considered a serious issue unless they are severe or frequent.
D: Increased vaginal discharge is a common symptom of pregnancy and is usually not a cause for alarm unless accompanied by other symptoms like itching or a foul odor.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct findings to report to the provider are A, B, D, E, and F. A - Abdominal assessment is crucial as it can indicate underlying issues. B - Vaginal discharge can be a sign of infection or other gynecological problems. D - Temperature abnormalities can signal infection or systemic issues. E - Dyspareunia (painful intercourse) may indicate underlying conditions. F - Condom usage is important for assessing safe sex practices. These findings are relevant for the provider to assess and potentially address any health concerns.