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A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
- A. Monitor blood glucose levels.
- B. Monitor intake and output.
- C. Monitor weight.
- D. Monitor axillary temperature.
Correct Answer: A
Rationale: The correct answer is A: Monitor blood glucose levels. Newborns who are small for gestational age (SGA) are at risk for hypoglycemia due to inadequate glycogen stores. Monitoring blood glucose levels is crucial to detect and manage hypoglycemia promptly. Monitoring intake and output (B) is important but not the priority in this case. Monitoring weight (C) is essential for assessing growth but does not directly address the immediate risk of hypoglycemia. Monitoring axillary temperature (D) is important for detecting infection or hypothermia but does not address the specific needs of an SGA newborn.
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A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 97.6°F. Which of the following is the priority nursing action?
- A. Witness the signature for informed consent for surgery.
- B. Initiate IV access.
- C. Insert an indwelling urinary catheter.
- D. Prepare the abdominal and perineal areas.
Correct Answer: B
Rationale: The correct answer is B: Initiate IV access. The priority nursing action in this scenario is to ensure IV access to administer necessary medications or fluids in case of an emergency. The client's vital signs indicate hypotension and tachycardia, which could be signs of hypovolemic shock due to significant bleeding. Initiating IV access promptly can help stabilize the client's condition and prevent further complications.
Choice A is incorrect because obtaining informed consent for surgery is not the immediate priority in this situation. Choice C is incorrect as inserting a urinary catheter is not urgent compared to addressing the potential hypovolemia. Choice D is incorrect as preparing the abdominal and perineal areas is not as urgent as addressing the client's hemodynamic instability.
A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?
- A. Bowel sounds
- B. Respiratory rate
- C. Temperature
- D. Fetal heart rate (FHR)
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Magnesium sulfate is a medication that can cause respiratory depression. Monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or depression promptly. This assessment is a priority because respiratory depression can lead to serious complications, including respiratory arrest. Assessing bowel sounds (choice A), temperature (choice C), and fetal heart rate (choice D) are important but not as critical as monitoring the respiratory rate when administering magnesium sulfate. Bowel sounds may indicate gastrointestinal motility issues, temperature changes may indicate infection, and fetal heart rate is important in pregnancy but not the priority when administering magnesium sulfate.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use.
- B. Blunt force trauma.
- C. Hypertension.
- D. Cigarette smoking.
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption due to the increased pressure on the placenta, leading to separation from the uterine wall. Cocaine use (A) and cigarette smoking (D) can also increase the risk but are not as common as hypertension. Blunt force trauma (B) can cause a sudden separation of the placenta but is less common compared to hypertension in a routine prenatal setting.
A nurse is caring for a client who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?
- A. Large amount of vaginal bleeding
- B. Uterine enlargement greater than expected for gestational age
- C. Severe nausea and vomiting
- D. Unilateral, cramp-like abdominal pain
Correct Answer: D
Rationale: The correct answer is D. Unilateral, cramp-like abdominal pain is a classic symptom of an ectopic pregnancy. This pain occurs due to the fallopian tube stretching or rupturing as the embryo grows. This is different from a normal intrauterine pregnancy, where the pain would be central or bilateral.
A: Large amount of vaginal bleeding is not a typical symptom of an ectopic pregnancy.
B: Uterine enlargement greater than expected for gestational age would be seen in a normal intrauterine pregnancy, not an ectopic pregnancy.
C: Severe nausea and vomiting are common symptoms of early pregnancy but are not specific to ectopic pregnancy.
In summary, the key to identifying an ectopic pregnancy is recognizing the combination of abdominal pain and the location of the pain.
A nurse is caring for a newborn and auscultates an apical heart rate of 130/min. Which of the following actions should the nurse take?
- A. Prepare the newborn for transport to the NICU.
- B. Call the provider to further assess the newborn.
- C. Ask another nurse to verify the heart rate.
- D. Document this as an expected finding.
Correct Answer: D
Rationale: The correct answer is D: Document this as an expected finding. In a newborn, a heart rate of 130/min is within the normal range (120-160/min). The nurse does not need to take any immediate action as this heart rate is considered normal for a newborn. Documenting this finding is important for ongoing assessment and continuity of care.
Choice A is incorrect because there is no indication for transport to the NICU based solely on the heart rate. Choice B is unnecessary as further assessment is not warranted for a normal heart rate. Choice C is not needed as the nurse is capable of accurately assessing the heart rate.