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A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C. Removing all clothing from the newborn except the diaper during phototherapy is essential as it helps maximize the skin surface area exposed to the light, thus enhancing the effectiveness of the treatment. This allows for better absorption of the light by the skin, aiding in the breakdown of bilirubin.
A: Feeding the newborn water every 4 hours is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion to the newborn's skin may interfere with the effectiveness of phototherapy and should be avoided.
D: Discontinuing therapy if a rash develops is not advisable, as a rash is a common side effect of phototherapy and does not necessarily require therapy cessation.
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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 most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed. Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary. Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?
- A. Determine progression of dilatation and effacement.
- B. Perform Leopold maneuvers.
- C. Complete a sterile speculum exam.
- D. Prepare a Nitrazine paper test.
Correct Answer: B
Rationale: The correct answer is B: Perform Leopold maneuvers. Prior to applying an external transducer for fetal monitoring, the nurse should perform Leopold maneuvers to assess the fetal position, presentation, lie, and engagement. This helps in determining the optimal placement of the transducer for accurate monitoring of the fetal heart rate. It allows the nurse to locate the fetal back and position the transducer over the fetal heart for the best signal quality.
Choices A, C, and D are incorrect:
A: Determining progression of dilatation and effacement is not necessary before applying the external transducer.
C: Completing a sterile speculum exam is not needed for fetal monitoring.
D: Preparing a Nitrazine paper test is unrelated to applying an external transducer.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression.
- B. Polyuria.
- C. Hypotension.
- D. Urticaria.
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can lead to mood changes, including depression, as a potential adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor and address any mental health concerns. Polyuria (increased urination) is not a common adverse effect of combined oral contraceptives. Hypotension (low blood pressure) is not typically associated with this medication. Urticaria (hives) is more commonly seen with allergic reactions rather than as a side effect of oral contraceptives.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate IV can cause toxicity leading to respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity as it antagonizes the effects of magnesium on the muscles. Having it readily available ensures prompt treatment in case of toxicity.
Restricting fluid intake (A) is not necessary for preeclampsia and can lead to dehydration. Assessing deep tendon reflexes (C) every 6 hours is important but not as crucial as having the antidote readily available. Monitoring intake and output (D) every 4 hours is important for overall assessment but does not directly address magnesium sulfate toxicity.
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. It is essential to maintain the client on bed rest to prevent further complications and to reduce the risk of dislodging the clot. Moving the affected leg could potentially dislodge the clot, leading to serious consequences such as pulmonary embolism. Administering aspirin for pain (choice A) is not appropriate as it can increase the risk of bleeding, especially in a patient receiving heparin. Massaging the affected leg (choice C) can also dislodge the clot and should be avoided. Applying cold compresses (choice D) can potentially exacerbate the situation by causing vasoconstriction and increasing the risk of clot formation.