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A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hours.
- B. Apply moisturizing lotion to the newborn's skin every 4 hours.
- C. Reposition the newborn every 2 to 3 hours.
- D. Give the newborn 1 oz of glucose water every 4 hours.
Correct Answer: C
Rationale: Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.
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A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.
Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy. What additional care should the nurse consider?
- A. Administering prophylactic antibiotics to prevent infection.
- B. Assessing for signs of jaundice in the newborn.
- C. Monitoring the client's vital signs for stability.
- D. Educating the client on breastfeeding techniques.
Correct Answer: B
Rationale: Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.
A nurse is providing dietary teaching to a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following food suggestions should the nurse include?
- A. Peanut butter sandwich.
- B. Sliced apples.
- C. Glass of skim milk.
- D. Scrambled egg.
Correct Answer: B
Rationale: Apples are low in phenylalanine, making them a safe option for individuals with phenylketonuria. They provide essential nutrients without contributing to phenylalanine accumulation.
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. This shot may be given after birth to protect future pregnancies.
- B. If my partner is Rh-negative, I will not receive the shot.
- C. I will receive the shot after delivery if my baby is Rh-negative.
- D. I should not receive any immunizations for 3 months after the shot.
Correct Answer: A
Rationale: Rho(D) immune globulin administered postpartum prevents maternal sensitization to Rh-positive fetal blood cells, reducing risks of hemolytic disease in subsequent pregnancies by suppressing maternal immune response.
A nurse is providing teaching to a group of clients about risk factors for ovarian cancer. Which of the following risk factors should the nurse include?
- A. Nulliparity.
- B. History of breastfeeding.
- C. Use of postmenopausal estrogen.
- D. Previous use of oral contraceptives.
- E. History of breast cancer.
Correct Answer: A,C,E
Rationale: Nulliparity (A) increases ovarian cancer risk by prolonging ovulation periods. Postmenopausal estrogen (C) elevates risk by stimulating cell proliferation. History of breast cancer (E) correlates with increased risk due to shared genetic mutations like BRCA1/2.