Nokea
A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Swaddle the newborn tightly
- B. Provide frequent tactile stimulation
- C. Position the newborn in a prone position
- D. Offer large feedings every 4 hours
Correct Answer: A
Rationale: The correct action for the nurse to take when caring for a newborn with neonatal abstinence syndrome is to swaddle the newborn tightly. Swaddling helps to provide comfort and reduce irritability in these newborns. Choice B, providing frequent tactile stimulation, may exacerbate the symptoms of neonatal abstinence syndrome by overstimulating the newborn. Choice C, positioning the newborn in a prone position, is not recommended as it increases the risk of sudden infant death syndrome (SIDS). Choice D, offering large feedings every 4 hours, is not appropriate as newborns with neonatal abstinence syndrome may have feeding difficulties and need smaller, more frequent feedings.
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A nurse is assessing a client who is in the first stage of labor and has an external fetal monitor in place. The nurse observes early decelerations in the fetal heart rate. Which of the following actions should the nurse take?
- A. Continue to monitor the fetal heart rate
- B. Reposition the client
- C. Administer oxygen via face mask
- D. Increase the rate of the IV fluids
Correct Answer: A
Rationale: Early decelerations are a benign finding that typically indicate fetal head compression, a normal response to uterine contractions. They do not require intervention as they are not associated with fetal compromise. The appropriate action for the nurse in this scenario is to continue to monitor the fetal heart rate. Repositioning the client, administering oxygen, or increasing IV fluids are not indicated responses to early decelerations and could be unnecessary or potentially harmful.
A nurse is preparing to administer Rh immune globulin to a client who is 28 weeks gestation. The nurse should understand that Rh immune globulin is administered to prevent which of the following?
- A. Rh incompatibility
- B. Severe preeclampsia
- C. Placental abruption
- D. Erythroblastosis fetalis
Correct Answer: A
Rationale: The correct answer is A: Rh incompatibility. Rh immune globulin is administered to prevent the formation of antibodies in clients who are Rh-negative and have been exposed to Rh-positive fetal blood. Severe preeclampsia (choice B) is a condition characterized by high blood pressure and signs of damage to organs, not prevented by Rh immune globulin. Placental abruption (choice C) is the separation of the placenta from the uterine wall, not prevented by Rh immune globulin. Erythroblastosis fetalis (choice D) is a condition where maternal antibodies attack fetal red blood cells due to Rh incompatibility, which Rh immune globulin helps prevent.
A nurse is assessing a client who is 2 hours postpartum and is receiving oxytocin to control postpartum bleeding. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 80/50 mm Hg
- B. Uterine contractions
- C. Urine output 150 mL in 2 hours
- D. Client reports cramping
Correct Answer: A
Rationale: The correct answer is A: 'Blood pressure 80/50 mm Hg.' Hypotension can be a side effect of oxytocin administration. A blood pressure of 80/50 mm Hg should be reported to the provider. Choice B, 'Uterine contractions,' is an expected finding as oxytocin is used to stimulate uterine contractions. Choice C, 'Urine output 150 mL in 2 hours,' is within the expected range postpartum. Choice D, 'Client reports cramping,' is a common finding due to uterine contractions and is not a cause for concern unless excessive or severe.
A client who is 2 days postpartum and breastfeeding reports nipple soreness. Which of the following instructions should the nurse provide?
- A. Avoid using a breast pump.
- B. Apply breast milk to the nipples after feedings.
- C. Feed the newborn less frequently.
- D. Use a nipple shield during feedings.
Correct Answer: B
Rationale: The correct instruction for the nurse to provide is to advise the client to apply breast milk to the nipples after feedings. Breast milk has healing properties and can help soothe sore nipples. Option A is incorrect because avoiding the use of a breast pump does not directly address nipple soreness. Option C is incorrect as feeding the newborn less frequently can lead to engorgement and further complications. Option D is incorrect as using a nipple shield during feedings may not address the underlying issue of soreness and can sometimes even worsen the situation.
A nurse is providing prenatal education to a client who is in the second trimester of pregnancy. Which of the following statements should the nurse include?
- A. You should expect to feel your baby move at 12 weeks.
- B. You will need to increase your calcium intake during pregnancy.
- C. You should avoid exercise during the second trimester.
- D. You will need to limit your intake of folic acid during pregnancy.
Correct Answer: B
Rationale: The correct answer is B. Calcium intake is crucial during pregnancy to support fetal bone development. The nurse should educate the client to increase their calcium intake. Choice A is incorrect because fetal movements are usually felt around 18-25 weeks, not at 12 weeks. Choice C is incorrect as exercise is generally encouraged during pregnancy, including the second trimester, as long as it is not high-impact or risky. Choice D is incorrect as folic acid intake is essential during pregnancy to prevent neural tube defects, and pregnant individuals are usually advised to increase their folic acid intake.