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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 hr
- B. Apply moisturizing lotion to the newborn's skin every 4 hr
- C. Give the newborn 1 oz of glucose water every 4 hr
- D. Reposition the newborn every 2 to 3 hr
Correct Answer: D
Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin.
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A nurse is caring for a client who is experiencing urinary incontinence. Which of the following recommendations should the nurse include in the teaching plan for this client?
- A. Drink large amounts of water before bedtime
- B. Perform Kegel exercises regularly
- C. Limit fiber in the diet to avoid bowel irritation
- D. Increase intake of caffeinated and carbonated beverages
Correct Answer: B
Rationale: Kegel exercises help strengthen the pelvic floor muscles, which can improve bladder control and reduce urinary incontinence. The nurse should instruct the client to practice these exercises regularly.
A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Hypertonia
- B. Jitteriness
- C. Acrocyanosis
- D. Generalized petechiae
Correct Answer: B
Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day
- B. Initiate seizure precautions for the client
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
- D. Encourage the client to ambulate twice per day
Correct Answer: B
Rationale: The nurse should initiate seizure precautions because severe preeclampsia poses a high risk for seizures (eclampsia), ensuring the safety of the client.
A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct Answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences.
Which of the following characteristics would indicate true labor in a client?
- A. Contractions are irregular and painless
- B. Fetus moves to an anterior position
- C. Bloody show is not present
- D. Contractions are regular in frequency
Correct Answer: D
Rationale: True labor is characterized by regular contractions that increase in intensity and frequency. These contractions result in cervical dilation and effacement, indicating the onset of labor.