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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A nurse is providing teaching to the parents of a newborn about the Plastibell circumcision technique. Which of the following information should the nurse include?
- A. The Plastibell will be removed 4 hours after the procedure.
- B. Make sure the newborn’s diaper is snug.
- C. Yellow exudate will form at the surgical site in 24 hours.
- D. Notify the provider if the end of your baby’s penis appears dark red.
Correct Answer: D
Rationale: Correct Answer: D: Notify the provider if the end of your baby’s penis appears dark red.
Rationale: Dark red color at the end of the baby's penis could indicate infection or poor circulation, which are concerning post-circumcision. Promptly notifying the provider can help prevent potential complications.
Summary of other choices:
A: The Plastibell is usually removed after a few days, not 4 hours.
B: Ensuring a snug diaper is not directly related to the Plastibell circumcision technique.
C: Yellow exudate at the surgical site is normal and expected, not a cause for concern.
E, F, G: Not provided in the question, so not applicable.
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
- A. Vomiting
- B. Hypertension
- C. Epigastric pain
- D. Contractions
Correct Answer: D
Rationale: Contractions can indicate preterm labor, a potential complication following amniocentesis. Vomiting, hypertension, and epigastric pain are less directly related to the procedure.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: Decreased temperature, lethargy, poor feeding, and respiratory distress are consistent with sepsis. Yellow sclera and oral mucosa are consistent with hyperbilirubinemia.
Which of the following is a potential barrier to implementing evidence-based practice in maternal and newborn healthcare?
- A. Resistance to change
- B. Limited access to technology
- C. Lack of funding
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Resistance to change can hinder implementation as healthcare professionals may be reluctant to adopt new practices. Limited access to technology can impede the use of evidence-based tools and resources. Additionally, lack of funding can prevent healthcare facilities from investing in necessary training and resources for evidence-based practice. Therefore, all these factors collectively serve as potential barriers to implementing evidence-based practice in maternal and newborn healthcare.
Which of the following is a potential indication for a forceps-assisted delivery?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Prolonged second stage of labor
- D. All of the above
Correct Answer: C
Rationale: A prolonged second stage of labor is a common indication for a forceps-assisted delivery.
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