Nokea
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: Remove all clothing from the newborn except the diaper. This is essential during phototherapy to maximize the skin's exposure to the light. The light helps breakdown bilirubin in the skin, reducing jaundice. Choice A is incorrect as water will not treat hyperbilirubinemia. Choice B is incorrect as lotions can interfere with the effectiveness of phototherapy. Choice D is incorrect as a rash is a common side effect of phototherapy and should not lead to discontinuation unless severe.
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A nurse is planning care for a toddler who has epiglottitis. which of the following interventions should the nurse include.
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions
Correct Answer: C
Rationale: Epiglottitis is a medical emergency, and droplet precautions are necessary to prevent the spread of infection. Suctioning the oropharynx can worsen airway obstruction and is not recommended.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. During this phase, contractions are strong and frequent, with the cervix dilating from 6 to 10 cm. The client may experience rectal pressure due to the baby descending. In the passive descent phase (choice A), the cervix is not fully dilated. Early phase (choice C) is typically from 0 to 6 cm dilation. Descent (choice D) is not a specific phase of labor. Other choices are not applicable in this context.
Which of the following is a potential indication for induction of labor?
- A. Preeclampsia
- B. Gestational diabetes
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Preeclampsia is a common indication for the induction of labor.
What is the recommended method of feeding for a full-term newborn who is not at risk for hypoglycemia?
- A. Breastfeeding
- B. Formula feeding
- C. Tube feeding
- D. All of the above
Correct Answer: A
Rationale: Breastfeeding is the recommended method of feeding for full-term newborns who are not at risk for hypoglycemia.
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: