Nokea
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include?
- A. Feed the newborn 5 to 10 min per breast.
- B. Offer the newborn 30 mL (1 oz) of water between feedings.
- C. Expect two to four wet diapers every 24 hr.
- D. Allow the baby to feed at least every 3 hr.
Correct Answer: D
Rationale: The correct answer is D: Allow the baby to feed at least every 3 hr. This instruction is essential to ensure the newborn receives adequate nutrition and maintains a healthy breastfeeding schedule. Feeding every 3 hours helps in establishing a proper feeding routine, ensures the baby gets enough milk, stimulates milk production in the mother, and helps prevent issues like engorgement and mastitis.
Choice A is incorrect because feeding time should not be restricted to a specific duration. Choice B is incorrect as water is unnecessary for newborns who are exclusively breastfed. Choice C is incorrect as the number of wet diapers can vary and is not a reliable indicator of sufficient milk intake. Choices E, F, and G are not provided.
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A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?
- A. Abdominal distention
- B. Petechiae
- C. Increased muscle tone
- D. Jitteriness
Correct Answer: D
Rationale: The correct answer is D: Jitteriness. Neonates born to mothers with gestational diabetes are at risk for hypoglycemia due to the abrupt cessation of the maternal glucose supply postnatally. Jitteriness is a common manifestation of hypoglycemia in newborns. It is important for the nurse to monitor for this sign as it indicates the need for prompt intervention to prevent further complications. Abdominal distention, petechiae, and increased muscle tone are not typically associated with hypoglycemia in newborns born to mothers with gestational diabetes.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns exposed to addictive substances in utero. Excessive crying is a common manifestation due to neurological irritability. Diminished deep tendon reflexes (A) would not be expected as the central nervous system is hyperactive. Decreased muscle tone (C) is unlikely as muscle rigidity or tremors are more common. Absent Moro reflex (D) is not typically seen as it is a primitive reflex present in newborns.
A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?
- A. Allow the medication to reach room temperature prior to administration.
- B. Place the client in a semi-Fowler’s position for 1 hr after administration.
- C. Instruct the client to avoid urinary elimination until after administration.
- D. Verify that informed consent is obtained prior to administration.
Correct Answer: D
Rationale: The correct answer is D: Verify that informed consent is obtained prior to administration. This is crucial because dinoprostone is a medication used to induce labor, which carries risks and requires informed consent. Without informed consent, the client may not fully understand the potential risks and benefits of the medication.
Choice A is incorrect because room temperature is not a specific requirement for administering dinoprostone. Choice B is incorrect as there is no evidence to support placing the client in a semi-Fowler's position after administration. Choice C is incorrect as avoiding urinary elimination is not necessary for this medication.
In summary, obtaining informed consent is the most important action to ensure the client understands the implications of the medication, making choice D the correct answer.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can lead to seizures due to drug withdrawal. Seizure precautions involve ensuring a safe environment, padded crib, monitoring vital signs closely, and having emergency medications and equipment readily available. Monitoring blood glucose every hour (A) is not typically necessary for neonatal abstinence syndrome. Placing the infant on their back with legs extended (B) is a basic positioning technique and not specific to addressing the syndrome. Providing a stimulating environment (D) would be inappropriate and could exacerbate symptoms.
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the McRoberts maneuver involves hyperflexing the mother's legs against her abdomen. This action helps to widen the pelvic outlet and reduce the angle of the pubic symphysis, facilitating the delivery of the infant's shoulder. Pressing on the fundus (A) does not address the shoulder dystocia issue. Pressing on the suprapubic area (B) may not provide the necessary assistance in this situation. Moving the client onto their hands and knees (C) does not facilitate the specific maneuver required. Therefore, assisting the client in pulling their knees toward their abdomen (D) is the correct action in this scenario.