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A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose level every hr. Neonatal abstinence syndrome can lead to hypoglycemia in infants. Monitoring blood glucose levels every hour allows for early detection and intervention. Providing a stimulating environment (A) can worsen symptoms. Initiating seizure precautions (C) is not necessary unless seizures are present. Placing the infant on his back with legs extended (D) does not address the specific issue of neonatal abstinence syndrome.
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A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. Hemolytic disease in newborns is caused by Rh incompatibility, where the mother is Rh negative and the father is Rh positive. This leads to the mother developing antibodies against the Rh-positive fetal red blood cells, resulting in hemolysis in the fetus. The other choices are incorrect because Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, not when both parents are Rh positive (choice C) or both are Rh negative (choice D). This educational program should emphasize the importance of Rh factor compatibility in preventing hemolytic disease in newborns.
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1-hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1-hour glucose tolerance test. At 24 weeks, it is important to screen for gestational diabetes. This test helps assess the body's ability to metabolize glucose. The other choices are not typically done at the 24-week appointment. B: Rubella titer is usually done earlier in pregnancy to check immunity. C: Group B strep culture is usually done around 35-37 weeks. D: Blood type and Rh are usually checked at the first prenatal visit.
A nurse is assessing a client who is 27 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/mm³
- C. Creatinine 0.8 mg/dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/mm³. In pre-eclampsia, there is a risk of developing HELLP syndrome, which includes hemolysis, elevated liver enzymes, and low platelet count. A platelet count of 60,000/mm³ indicates thrombocytopenia, a serious complication that can lead to bleeding and should be reported to the provider urgently. Choices A, C, and D are within normal limits for a pregnant client and are not indicative of an immediate concern in pre-eclampsia.
A client who is 16 weeks of gestation asks the nurse how to prepare her toddler for a younger sibling.
- A. You should hold your newborn in your arms when you introduce him to your toddler
- B. You should move your toddler out of her crib 2 weeks prior to your due date
- C. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born
- D. You should place your toddler in timeout if she exhibits regressive behavior after the baby is born
Correct Answer: B
Rationale: The correct answer is B because moving the toddler out of the crib before the baby arrives allows the toddler time to adjust to the change without associating it directly with the baby's arrival. Holding the newborn in your arms (A) may make the toddler feel left out. Placing the toddler in timeout (C, D) for regressive behavior can create negative associations with the new sibling.
A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy. This of the following statements by the client indicates an understanding of the teaching.
- A. “I will count baby’s lacks every other day.
- B. “I will alternate the arm use to check my blood pressure
- C. I will check my urine for protein daily
- D. I will consume 50 grams of protein daily
Correct Answer: C
Rationale: The correct answer is C: "I will check my urine for protein daily." This is the correct answer because monitoring urine for protein is crucial in managing preeclampsia. Proteinuria is a key marker for worsening preeclampsia as it indicates kidney damage. By checking urine daily, the client can detect early signs of deterioration and seek medical help promptly.
Answers A, B, and D are incorrect because they do not directly relate to monitoring preeclampsia. Counting baby's kicks (A) and alternating arm use for blood pressure checks (B) are important but not as critical as monitoring proteinuria. Consuming 50 grams of protein daily (D) is beneficial for overall health during pregnancy but does not specifically address the management of preeclampsia.