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A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother states 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Insist that the mother pick up the newborn to feed him
- B. Demonstrate how to hold a newborn and allow the client to practice
- C. Persuade the client to breastfeed the newborn to promote bonding
- D. Offer to take the newborn to the nursery to finish his feeding
Correct Answer: B
Rationale: The correct answer is B: Demonstrate how to hold a newborn and allow the client to practice. This option respects the mother's decision while also providing education and support. By demonstrating proper newborn holding techniques and allowing the client to practice, the nurse can ensure the baby's safety and promote bonding between the mother and newborn. Insisting on the mother picking up the newborn (choice A) goes against her wishes and may create tension. Persuading the client to breastfeed (choice C) may not be feasible or appropriate at that moment. Taking the newborn to the nursery (choice D) may not align with the mother's preferences.
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A nurse is teaching about clomiphene citrate to a client who is experiencing infertility. Which of the following adverse effect should the nurse include?
- A. Tinnitus
- B. Urinary Frequency
- C. Breast Tenderness
- D. Chills
Correct Answer: C
Rationale: The correct answer is C: Breast Tenderness. Clomiphene citrate is a medication commonly used for infertility, and a common side effect is breast tenderness due to its estrogen-like effects on the body. Tinnitus (A), urinary frequency (B), and chills (D) are not typically associated with clomiphene citrate. Tinnitus could be related to ototoxic medications, urinary frequency could be due to diuretics, and chills could be due to infections or allergic reactions, but they are not commonly linked to clomiphene citrate. Therefore, the nurse should focus on educating the client about the potential adverse effect of breast tenderness when taking clomiphene citrate.
A nurse is assessing a client during her first prenatal visit. The client reports March 20th as her last menstrual period. Use Nagele's rule to calculate the estimated date of delivery.
- A. 03/20
- B. 12/27
- C. 11/27
- D. 10/03
Correct Answer: B
Rationale: The correct answer is B: 12/27. Nagele's rule calculates the estimated due date by adding 7 days to the first day of the last menstrual period, then subtracting 3 months and adding 1 year. In this case, March 20th + 7 days = March 27th. Subtracting 3 months gives us December 27th. Adding 1 year, we get December 27th of the current year as the estimated due date. Choice A is incorrect because it does not follow Nagele's rule. Choice C is incorrect as it is not 3 months subtracted from the reported last menstrual period. Choice D is incorrect as it does not account for the necessary adjustments according to Nagele's rule.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
A nurse is providing teaching to a client who is receiving medroxyprogesterone IM for contraception. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should discontinue this medication if I experience spotting
- B. I will need to return to the clinic in the next eight weeks for my next injection
- C. I should increase my calcium intake while taking this medication
- D. I will get two shots each time I receive this medication
Correct Answer: B
Rationale: The correct answer is B. Returning to the clinic in 8 weeks for the next injection indicates an understanding of the medication schedule. Medroxyprogesterone is typically given every 11 to 13 weeks, so returning in 8 weeks would align with the correct timing for the next injection. This demonstrates the client's comprehension of the dosing regimen.
Incorrect choices:
A: Discontinuing the medication if spotting occurs is not correct as spotting can be a common side effect of medroxyprogesterone.
C: Increasing calcium intake is not specifically related to medroxyprogesterone IM for contraception.
D: Getting two shots each time is incorrect as typically only one injection is given.
Overall, choice B is the correct answer based on the medication's dosing schedule, while the other choices do not align with the appropriate understanding of medroxyprogesterone IM for contraception.
A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. newborn who has nasal flaring
- B. newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring indicates respiratory distress, which is a priority concern in newborns as it can lead to hypoxia. The nurse should assess this newborn first to ensure adequate oxygenation.
B: Subconjunctival hemorrhage is common and not an urgent issue.
C: Overlapping suture lines are normal in newborns and do not require immediate attention.
D: Not passing rust-stained urine could indicate a metabolic issue but is not as urgent as respiratory distress.