Nokea
A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: The correct answer is A: Decrease the lighting levels in the nursery. Neonatal abstinence syndrome causes sensitivity to stimuli, including light. By decreasing lighting levels, the nurse can help reduce overstimulation and promote a calm environment for the newborn. This can aid in soothing the baby and decreasing symptoms associated with the syndrome.
Choice B is incorrect because wrapping the newborn loosely in a blanket may not directly address the sensitivity to light and other stimuli. Choice C, providing frequent stimulation, would likely exacerbate the symptoms of neonatal abstinence syndrome due to the increased sensory input. Choice D, encouraging frequent eye contact during feedings, could also lead to overstimulation for the newborn.
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A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. This phase is characterized by more rapid cervical dilation (6-10 cm) and increased contractions with shorter intervals. The client's symptoms align with this phase as they are experiencing strong contractions close together, along with increased rectal pressure indicating descent of the fetus. Other choices are incorrect as: A (Passive descent) occurs during the second stage of labor; C (Early phase) is typically before 6 cm dilation; D (Descent) is not a recognized phase of labor.
A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: The correct answer is A: Apply warm compresses on the breasts before feedings. Warm compresses help to promote milk flow and relieve engorgement by increasing blood flow to the area. This can make it easier for the baby to latch and feed effectively. It is important to address engorgement promptly to prevent complications such as blocked ducts or mastitis.
Option B is incorrect because allowing the infant to nurse on one breast per feeding may not fully empty the breasts, leading to further engorgement. Option C is incorrect because aspirin is not recommended during breastfeeding due to potential risks to the infant. Option D is incorrect because wearing a tight-fitting underwire bra can constrict the breasts and worsen engorgement.
A nurse who is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rh(0) Immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rh(0) Immune globulin. This is the priority intervention because the client is Rh-negative and has undergone an invasive procedure that could potentially lead to mixing of maternal and fetal blood, increasing the risk of Rh sensitization. Administering Rh(0) Immune globulin helps prevent this sensitization by destroying any fetal Rh-positive red blood cells that may have entered the maternal circulation. Checking the client's temperature (A) is important but not the priority. Observing for uterine contractions (B) is relevant but not as urgent as administering Rh(0) Immune globulin. Monitoring the fetal heart rate (D) is also important, but preventing Rh sensitization takes precedence in this scenario.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.
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 can indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and protein in the urine. Preeclampsia poses risks to both the mother and the baby, so prompt reporting to the provider is crucial for timely intervention. Varicose veins in the calves (B) are common in pregnancy due to increased pressure on the veins but do not require immediate provider notification. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy and is not typically concerning unless it worsens significantly. Hyperpigmentation of the cheeks (D) is a common benign finding known as melasma and does not require immediate reporting unless accompanied by other concerning symptoms.