Nokea
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.
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The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant?
- A. Encouraging the mother to supplement breast-feeding with formula.
- B. Keeping the infant NPO until the second period of reactivity.
- C. Encouraging the mother to breastfeed the infant every 2 to 3 hours.
- D. Placing the infant under phototherapy.
Correct Answer: C
Rationale: The correct answer is C: Encouraging the mother to breastfeed the infant every 2 to 3 hours. Breastfeeding frequently helps prevent jaundice by promoting the excretion of bilirubin through stool. This helps prevent bilirubin buildup in the baby's body, reducing the risk of jaundice. Encouraging frequent breastfeeding also ensures the infant receives adequate hydration, which aids in the elimination of bilirubin.
Choice A is incorrect because supplementing with formula can interfere with breastfeeding and affect bilirubin excretion. Choice B is incorrect because keeping the infant NPO can lead to dehydration and decreased bilirubin excretion. Choice D is incorrect because phototherapy is a treatment for jaundice, not prevention.
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, “How will I know if my baby gets enough breast milk?” Which of the following responses should the nurse make?
- A. Your baby should wet 6 to 8 diapers per day.
- B. Your baby should have a wake cycle of 30 to 60 minutes after each feeding.
- C. Your baby should burp after each feeding.
- D. Your baby should sleep at least 6 hours between feedings.
Correct Answer: A
Rationale: The correct answer is A: Your baby should wet 6 to 8 diapers per day. This is because the frequency of wet diapers indicates that the newborn is getting enough breast milk. An adequate amount of wet diapers signifies that the baby is adequately hydrated and receiving sufficient nourishment. It is a concrete and measurable way to monitor the baby's intake.
Choice B is incorrect because the wake cycle after feeding varies among newborns and is not a reliable indicator of milk intake. Choice C is incorrect as burping after feeding is a normal process but not necessarily an indicator of sufficient milk intake. Choice D is incorrect because newborns typically need to feed more frequently than every 6 hours.
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse?
- A. You can push the baby to the room in a wheeled bassinet.
- B. If you show me your photo identification, you can take the infant.
- C. Have the mother ring, and I will take the baby to the room.
- D. You may carry your grandchild to the room.
Correct Answer: C
Rationale: The correct response is C: Have the mother ring, and I will take the baby to the room. This is the appropriate response because it ensures the safety and security of the newborn by confirming the mother's approval before allowing the grandmother to take the baby to the room. This step is crucial to prevent any unauthorized individuals from taking the baby without the mother's consent.
Choice A is incorrect because pushing the baby to the room in a wheeled bassinet may not involve verifying the mother's consent. Choice B is incorrect as asking for photo identification does not confirm the mother's approval. Choice D is incorrect as it assumes the grandmother can carry the baby without checking with the mother first.
In summary, choice C is the correct response as it prioritizes the safety and well-being of the newborn by ensuring the mother's consent is obtained before allowing the grandmother to take the baby to the room.
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
- A. Dorsogluteal
- B. Vastus lateralis
- C. Deltoid
- D. Ventrogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice D) can be used in older infants but is not the preferred site for newborns.
A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?
- A. It assists in identifying the location of the placenta and fetus.
- B. It is useful for estimating fetal age.
- C. This is a screening tool for spina bifida.
- D. This will determine if there is more than one fetus.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Prior to amniocentesis, an ultrasound is done to identify the location of the placenta and fetus. This is crucial to ensure the safety of the procedure. It helps in determining the best site for needle insertion to avoid harming the fetus or placenta. Additionally, it allows for visualization of any abnormalities that could affect the amniocentesis procedure.
Summary of other choices:
B: Estimating fetal age is not the primary purpose of the ultrasound before amniocentesis.
C: Screening for spina bifida is usually done through other specific tests, not the ultrasound before amniocentesis.
D: Determining if there is more than one fetus is not the main goal of the ultrasound before amniocentesis.