Nokea
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side of the finger has fewer nerve endings, which can reduce pain for the client. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect the accuracy of the test. Smearing the blood onto the reagent strip (choice B) can lead to incorrect results due to inadequate blood volume or improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and may result in a higher blood glucose reading. Therefore, selecting the lateral side of the finger for puncture is the most appropriate action to ensure accurate and less painful blood glucose monitoring.
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Which of the following is a potential ethical issue in maternal and newborn healthcare?
- A. Informed consent
- B. Patient confidentiality
- C. End-of-life decision-making
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. In maternal and newborn healthcare, ethical issues can arise in various aspects such as obtaining informed consent for procedures, ensuring patient confidentiality, and making difficult end-of-life decisions. Informed consent is crucial to respect patient autonomy. Patient confidentiality is vital to maintain trust and privacy. End-of-life decision-making involves complex ethical considerations. Choosing D is correct as all these issues are potential ethical concerns in this specific healthcare context. Choices A, B, and C alone are not comprehensive enough to cover the range of ethical issues that can arise in maternal and newborn healthcare.
Which of the following is a potential complication of neonatal hypoglycemia?
- A. Jaundice
- B. Respiratory distress syndrome
- C. Intraventricular hemorrhage
- D. All of the above
Correct Answer: D
Rationale: Neonatal hypoglycemia can lead to jaundice, respiratory distress syndrome, and intraventricular hemorrhage.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: A displaced uterus to the right above the umbilicus may indicate a full bladder. Assisting the client to empty their bladder helps the uterus return to its proper position and prevents complications like postpartum hemorrhage.
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy.
- C. The hepatitis B immunization should not be obtained until after you finish breastfeeding.
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during pregnancy to protect both the mother and the baby. Varicella and rubella vaccines are contraindicated during pregnancy.
A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Fetal anemia can lead to bradycardia due to reduced oxygen delivery to the fetal heart.