Nokea
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: The correct answer is D: Instruct the client to press the provided button each time fetal movement is detected. This action is essential during a nonstress test to monitor fetal heart rate and movement patterns. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, providing valuable information about the fetal well-being. Maintaining the client NPO (Option A) is not necessary for a nonstress test. Placing the client in a supine position (Option B) can decrease blood flow to the fetus. Instructing the client to massage the abdomen (Option C) may lead to inaccurate test results.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parent's chest, Encourage birthing parent to breastfeed, Obtain a prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring.
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E. The correct answer is to place newborn skin to skin on birthing parent's chest (A) to promote bonding and regulate temperature, and encourage breastfeeding (B) for nutrition and immune benefits. The potential condition the client is most likely experiencing is Cold stress (B), indicated by the need for phototherapy. The nurse should monitor Temperature (C) for signs of hypothermia and Bilirubin level (E) to assess jaundice severity. These interventions and parameters address the client's most likely condition and provide comprehensive care.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client’s condition to the local health department.
Correct Answer: D
Rationale: The correct answer is D: Report the client’s condition to the local health department. This is crucial to ensure proper monitoring, contact tracing, and prevention of transmission to others. Reporting the client's HIV status is mandatory for public health purposes. Administering penicillin G (choice A) is not relevant in this scenario. Instructing the client to schedule a pelvic exam (choice B) and starting HIV medication after delivery (choice C) are not immediate actions needed to address the client's HIV status.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lay in a supine position throughout the test.
- C. You should not eat or drink for 2 hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: The correct answer is D because pressing the handheld button when feeling the baby move helps monitor fetal heart rate and movements during the test. This action allows healthcare providers to assess the baby's well-being. Choice A is incorrect as the test duration varies. Choice B is wrong as the client should lay on their left side, not supine, to prevent compression of the vena cava. Choice C is incorrect as eating and drinking are not restricted before the test.
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 choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. This is the recommended site for administering vaccines to newborns due to the large muscle mass, reducing the risk of injury to nerves and blood vessels. It also allows for proper absorption of the vaccine. Option B is incorrect as vigorous massage can lead to tissue damage and discomfort. Option C is incorrect as the needle should be inserted at a 90° angle for intramuscular injections. Option D is incorrect as a smaller gauge needle (typically 25-27 gauge) is recommended for newborns to minimize pain and tissue trauma.