Nokea
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin to skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin to skin contact. This action is crucial to reduce the risk of HIV transmission from the mother to the newborn. By bathing the newborn before skin-to-skin contact, the nurse can remove any potential HIV-infected fluids from the baby's skin, reducing the risk of transmission. This step helps to protect the newborn while still allowing for important bonding through skin-to-skin contact after bathing.
Choice A is incorrect as the use of a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to newborn. Choice C is incorrect as stopping antiretroviral medication can significantly increase the risk of HIV transmission to the newborn. Choice D is incorrect as administering pneumococcal immunization is important but not within 4 hours following birth in the context of preventing HIV transmission.
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A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics
- B. Cleanse the site with Povidone iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial in preventing infection in a newborn with myelomeningocele where the spinal cord is exposed. Infection can lead to serious complications. Administering broad-spectrum antibiotics helps to reduce the risk of infection. Cleansing the site with Povidone iodine (choice B) is important, but antibiotics are necessary for prophylaxis. Monitoring rectal temperature (choice C) is not directly related to preventing infection. Surgical closure (choice D) after 72 hours is important, but antibiotics are essential immediately post-birth to prevent infection.
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 response promotes education and empowerment by showing the client the proper way to hold and feed the newborn, fostering a supportive and educational environment. Insisting on the mother picking up the newborn (choice A) disregards the mother's wishes and may lead to conflict. Persuading the client to breastfeed (choice C) may not be appropriate if the client has chosen bottle-feeding. Taking the newborn to the nursery (choice D) does not address the client's desire to feed her baby.
A nurse is assessing a client who is 27 weeks of gestation and has pre eclampsia. Which of the following findings should the nurse report to the provider?
- A. Hemoglobin 14.8 g/dL
- B. Platelet count 60,000/ mm
- C. Creatine 0.8 mg/ dL
- D. Urine protein concentration 200 mg/24hr
Correct Answer: B
Rationale: The correct answer is B: Platelet count 60,000/ mm. In pre-eclampsia, a low platelet count indicates thrombocytopenia, a serious complication that can lead to bleeding. This finding should be reported promptly to the provider for further evaluation and management. A: Hemoglobin level is within normal range and not a priority in pre-eclampsia. C: Creatinine level is normal and not directly related to the complications of pre-eclampsia. D: Urine protein concentration is elevated, which is expected in pre-eclampsia and should be monitored, but not as urgent as low platelet count.
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1 hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1 hour glucose tolerance test. At 24-week prenatal appointment, screening for gestational diabetes is crucial. This test helps identify any glucose intolerance in pregnant women. The other choices are incorrect because: B: Rubella titer is typically done earlier in pregnancy to assess immunity. C: Group B strep culture is usually done around 35-37 weeks to determine if the mother needs antibiotics during labor. D: Blood type and Rh testing are important but are usually done earlier in pregnancy to determine if the mother is Rh negative and needs Rhogam.
A nurse is caring for four enter-partum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client at 32 weeks of gestation reporting seeing floating spots first because it could indicate a serious condition called preeclampsia, characterized by high blood pressure and organ damage. This client's symptom is a sign of visual disturbances, a classic symptom of preeclampsia. Immediate assessment is necessary to prevent complications such as seizures and stroke. The other clients' symptoms, urinary frequency, leg cramps, and periodic numbness in fingers, are common discomforts in pregnancy but do not suggest immediate serious complications like preeclampsia.