Nokea
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn's temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. Phototherapy is used to treat jaundice by exposing the baby's skin to light. Lotions or ointments can interfere with the effectiveness of the light therapy. Dressing the newborn in lightweight clothing (choice A) is not directly related to the effectiveness of phototherapy. Keeping the newborn supine throughout treatment (choice C) is a general position recommendation and not specific to phototherapy. Measuring the newborn's temperature every 8 hours (choice D) is important but not directly related to phototherapy.
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A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?
- A. Document the findings and continue to monitor the client.
- B. Notify the client's provider.
- C. Increase the frequency of fundal massage.
- D. Encourage the client to empty her bladder.
Correct Answer: A
Rationale: The correct answer is A: Document the findings and continue to monitor the client. This is the appropriate action because the client's fundus is midline and firm, indicating good uterine tone. Lochia rubra and small clots are expected findings in the immediate postpartum period. The nurse should document these findings for future reference and continue to monitor the client's condition.
Choice B (Notify the client's provider) is incorrect because there are no concerning signs that warrant immediate provider notification, as the fundus is firm and midline.
Choice C (Increase the frequency of fundal massage) is unnecessary since the fundus is already firm at the umbilicus, indicating good uterine tone.
Choice D (Encourage the client to empty her bladder) is not the priority in this scenario, as the client's fundal assessment and lochia observations take precedence.
While evaluating the reflexes of the newborn, the nurse notes that with a loud noise the newborn symmetrically abduct and extend his arms, his fingers fan out and forms a c with the thumb and forefinger. What does the nurse document?
- A. Positive Moro reflex
- B. Positive Babinski reflex
- C. Rooting reflex
- D. Tonic neck reflex
Correct Answer: A
Rationale: The correct answer is A: Positive Moro reflex. The Moro reflex is elicited by a sudden loud noise or a jarring movement. The newborn symmetrically abducts and extends their arms, followed by fanning out their fingers and forming a "C" shape with the thumb and forefinger. This reflex is an involuntary response that indicates the normal development of the newborn's nervous system. The other choices are incorrect because:
B: Positive Babinski reflex is elicited by stroking the sole of the foot, resulting in the toes fanning out and big toe dorsiflexing.
C: Rooting reflex is elicited by touching the newborn's cheek, causing them to turn their head towards the stimulus and open their mouth to seek food.
D: Tonic neck reflex is elicited by turning the newborn's head to one side, causing extension of the arm on that side and flexion of the opposite arm.
A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus B-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicill in
- B. Azithro mycin
- C. Ceftriax one
- D. Acyclov ir
Correct Answer: A
Rationale: The correct answer is A: Ampicillin. Group B Streptococcus (GBS) infection during labor is typically treated with intravenous antibiotics like ampicillin to prevent transmission to the newborn. Ampicillin is the first-line treatment for GBS during labor due to its effectiveness in eradicating the bacteria and reducing the risk of neonatal infection. Azithromycin (B) is not typically used for GBS infection during labor. Ceftriaxone (C) is not the preferred antibiotic for GBS during labor. Acyclovir (D) is used to treat viral infections, not bacterial infections like GBS.
A client at 12 weeks' gestation reports nausea and vomiting. What is the best dietary advice?
- A. Eat three large meals a day.
- B. Drink fluids with meals.
- C. Consume small, frequent meals throughout the day.
- D. Avoid protein-rich foods.
Correct Answer: C
Rationale: The correct answer is C: Consume small, frequent meals throughout the day. This advice helps manage nausea and vomiting during pregnancy by preventing an empty stomach, which can worsen symptoms. Eating small, frequent meals helps stabilize blood sugar levels and provides a steady source of nutrients for the developing fetus. It also reduces the likelihood of triggering nausea by avoiding large meals. Drinking fluids with meals (choice B) may exacerbate symptoms by filling up the stomach too quickly. Eating three large meals a day (choice A) can lead to overeating and may worsen nausea. Avoiding protein-rich foods (choice D) is not recommended as protein is essential for fetal development and overall health during pregnancy.
What is the appropriate intervention for a mother with a third-degree perineal tear postpartum?
- A. Apply ice packs to the perineum
- B. Administer stool softeners as prescribed
- C. Encourage the mother to avoid heavy lifting
- D. Provide perineal exercises for faster recovery
Correct Answer: C
Rationale: The correct answer is C: Encourage the mother to avoid heavy lifting. After a third-degree perineal tear, it is crucial to prevent strain on the perineum to promote healing and prevent complications like infection or further tearing. Heavy lifting can increase pressure on the perineum, leading to delayed healing. Ice packs (A) may help reduce swelling initially but do not address the underlying issue. Stool softeners (B) can help prevent constipation and straining during bowel movements but do not directly impact perineal tear healing. Perineal exercises (D) are beneficial for strengthening the pelvic floor muscles in general but should be introduced gradually and not immediately postpartum with a severe tear.