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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. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: Correct Answer: C - Initiate seizure precautions.
Rationale: Infants with neonatal abstinence syndrome are at risk for seizures due to drug withdrawal. Initiating seizure precautions involves creating a safe environment to prevent injury during a seizure. This includes padding the crib, ensuring a clear space around the infant, and having emergency medications available. Monitoring blood glucose levels every hour (A) is not directly related to neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a basic positioning technique and does not address the specific needs of a baby with neonatal abstinence syndrome. Providing a stimulating environment (D) is contraindicated as it can exacerbate symptoms of withdrawal in the infant.
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A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: Correct Answer: D - Verify that informed consent is obtained prior to administration.
Rationale: Informed consent is a crucial ethical and legal requirement before any medical procedure. It ensures the client is aware of the risks, benefits, and alternatives to the treatment. Verifying informed consent protects the client's autonomy and prevents potential legal issues.
Incorrect Choices:
A: Allowing the medication to reach room temperature is not necessary for the administration of dinoprostone insert.
B: Placing the client in a semi-Fowler's position after administration is not a standard practice for this procedure.
C: Instructing the client to avoid urinary elimination is unnecessary and could lead to discomfort and potential complications.
E, F, G: No additional choices provided, but they would likely be incorrect as well as they do not address the key safety and ethical considerations associated with administering dinoprostone insert for labor induction.
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider because changes in these systems can indicate serious health issues. CNS findings may suggest neurological problems, while GI findings could indicate digestive issues or potential complications. Reporting these findings promptly allows the provider to assess the patient's condition thoroughly and intervene if necessary. Respiratory and oxygen saturation findings are important but may not always require immediate intervention. Other choices are not directly related to critical health concerns that need urgent attention.
A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis.
- A. Increased warmth in the extremity
- B. Tachycardia
- C. Leukocytosis
- D. Scant lochia rubra
- E. Decreased extremity edema
Correct Answer:
Rationale: Correct Answer:
Rationale:
1. Increased warmth in the extremity (Findings 24 hr later): Deep vein thrombosis can lead to increased warmth in the affected extremity due to inflammation.
2. Tachycardia (Indication of worsening condition): Tachycardia can indicate worsening condition or potential complications such as pulmonary embolism.
3. Leukocytosis (Indication of improving condition): Leukocytosis can indicate the body's response to infection or inflammation, which may be improving.
Other Choices:
D: Scant lochia rubra - Not relevant to the assessment of deep vein thrombosis.
E: Decreased extremity edema - Edema is not a typical finding associated with deep vein thrombosis.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?
- A. Deep tendon reflexes 4+
- B. Fundal height 14 cm
- C. Blood pressure 142/94 mm Hg
- D. FHR 152/min
Correct Answer: D
Rationale: The correct answer is D: FHR 152/min. At 18 weeks gestation, the fetal heart rate (FHR) typically ranges from 140-160 beats per minute, making 152/min within the normal range. This finding indicates a healthy fetal heart rate.
A: Deep tendon reflexes 4+ is not relevant to a routine assessment at 18 weeks gestation.
B: Fundal height of 14 cm is more indicative of around 12 weeks gestation, not 18 weeks.
C: Blood pressure of 142/94 mm Hg is elevated and would require further assessment and management, not expected at 18 weeks gestation.
In summary, the FHR of 152/min is the expected finding at 18 weeks gestation, making it the correct answer.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.