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A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
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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 observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying can help soothe the baby by providing comfort and closeness. This position mimics the feeling of being held in the womb and the swaying motion can be calming. Placing the newborn in the crib in a prone position (B) is not recommended due to the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may lead to overfeeding and potential nipple confusion. Preparing a bottle of formula mixed with rice cereal (D) is not recommended for newborns as their digestive systems are not ready for solids.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is a type of emergency contraception that is most effective when taken within 72 hours of unprotected sex. Taking it as soon as possible maximizes its effectiveness in preventing pregnancy by delaying or inhibiting ovulation. Choice B is incorrect as levonorgestrel can be used even if the person is on an oral contraceptive. Choice C is incorrect because a delayed period does not necessarily indicate pregnancy; a pregnancy test should be taken if there are other signs of pregnancy. Choice D is incorrect because levonorgestrel is only effective for a short period after taking it and does not provide long-term protection against pregnancy.
A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face.
- B. A newborn who is 32 hr old and has not passed a meconium stool.
- C. A newborn who is 12 hr old and has pink-tinged urine.
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F).
Correct Answer: B
Rationale: The correct answer is B. A newborn who is 32 hr old and has not passed a meconium stool should be reported to the provider. Meconium should be passed within the first 24-48 hours of life, so the delay could indicate an obstruction or other issue. Choices A, C, and D are all within normal ranges for newborn assessments and do not require immediate reporting to the provider. E, F, and G are not provided as options.
A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I will position my baby at a 45-degree angle in the car seat.
- B. I can place my baby in the front seat with the airbag turned off.
- C. I can turn my baby's car seat around when she weighs 15 pounds.
- D. I will place my baby in a forward-facing car seat in my back seat.
Correct Answer: A
Rationale: Correct Answer: A. "I will position my baby at a 45-degree angle in the car seat."
Rationale: Placing the newborn at a 45-degree angle in the car seat supports the baby's airway and prevents slumping, ensuring proper breathing and safety. This position helps reduce the risk of suffocation and allows the baby's head to be supported. It is recommended by pediatric experts as the safest way for a newborn to travel in a car seat.
Summary of other choices:
B: Placing a baby in the front seat with the airbag turned off is not safe, as the back seat is the safest place for children under 13 years old.
C: Turning the baby's car seat around at 15 pounds is incorrect as rear-facing is recommended until at least 2 years of age.
D: Using a forward-facing car seat for a newborn is unsafe, as infants should be in a rear-facing seat until they outgrow the height or weight limit.