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A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Vitamin B12 is mainly found in animal products, making it challenging for vegans to obtain sufficient amounts. Fortified soy milk is a great source of vitamin B12 for vegans. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12. It is important for the nurse to recommend a food source that is rich in vitamin B12 to help the client meet their nutritional needs.
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A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels as hypoglycemia is a common cause. Low blood glucose in a newborn can lead to seizures and long-term neurological damage. Monitoring blood glucose levels and promptly addressing any abnormalities is crucial. Total bilirubin (B) is important for assessing jaundice, not jitteriness. Hemoglobin (C) and blood calcium (D) are not typically related to jitteriness in a newborn.
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 as it helps to monitor the baby's heart rate in response to its movements, providing crucial information about fetal well-being. Pressing the button allows the nurse to correlate fetal movements with changes in the heart rate, helping to assess the baby's overall health and response to stimuli. Maintaining the client NPO (A) is not necessary for a nonstress test. Placing the client in a supine position (B) can decrease blood flow to the baby and is not recommended. Instructing the client to massage the abdomen (C) may artificially stimulate fetal movements, affecting the accuracy of the test results.
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 providing discharge teaching to a client following tubal ligation. Which of the following statements by the client indicates an understanding of the teaching?
- A. Premenstrual tension will no longer be present.
- B. My monthly menstrual period will be shorter.
- C. Hormone replacements will be needed following this procedure.
- D. Ovulation will remain the same.
Correct Answer: D
Rationale: The correct answer is D: Ovulation will remain the same. This statement indicates an understanding of tubal ligation, which is a permanent method of contraception that prevents pregnancy by blocking the fallopian tubes. Ovulation, the release of an egg from the ovary, will continue to occur after tubal ligation. This is because tubal ligation does not affect the hormonal process of ovulation.
Choice A is incorrect because premenstrual tension can still occur even after tubal ligation. Choice B is incorrect as tubal ligation does not affect the duration of menstrual periods. Choice C is incorrect because hormone replacements are not typically needed after tubal ligation unless there are other underlying medical conditions.
Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: [1, 0, 1]
The correct answers are A and C (Weigh perineal pads).
- A large bore IV catheter may be necessary for rapid fluid resuscitation in emergencies, indicated for critically ill patients.
- Weighing perineal pads is essential to monitor postpartum bleeding, ensuring accurate assessment and timely intervention.
- Assessing cervical dilation (B) is not typically a nursing action but a medical provider's task during labor.
- Administering methotrexate (D) is a medical intervention for conditions like ectopic pregnancy, not within a nurse's scope.