Nokea
A nurse is providing teaching about immunizations to a client who is pregnant. Which of the following statements should the nurse include in the teaching?
- A. The immunization for varicella should be given at least 1 month prior to delivery.
- B. You can receive the rubella immunization during the third trimester of pregnancy.
- C. The hepatitis B immunization should not be obtained until after you finish breastfeeding.
- D. You can receive the immunization for influenza at any time during your pregnancy.
Correct Answer: D
Rationale: The influenza vaccine is safe and recommended during pregnancy to protect both the mother and the baby. Varicella and rubella vaccines are contraindicated during pregnancy.
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A nurse is planning care for a toddler who has epiglottitis. which of the following interventions should the nurse include.
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions
Correct Answer: C
Rationale: Epiglottitis is a medical emergency, and droplet precautions are necessary to prevent the spread of infection. Suctioning the oropharynx can worsen airway obstruction and is not recommended.
A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open
- C. Both fontanels are the same size.
- D. Both fontanels show molding.
Correct Answer: B
Rationale: The anterior fontanel typically remains open until around 18 months of age, while the posterior fontanel usually closes by 2-3 months. Molding is not an expected finding at this age.
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. In newborns of mothers with gestational diabetes mellitus, hypoglycemia can occur due to the abrupt cessation of the maternal glucose supply. Jitteriness is a common manifestation of hypoglycemia in newborns. This is because the brain is highly dependent on glucose for energy, and low blood sugar levels can affect neurological function, leading to symptoms like jitteriness. Abdominal distention, petechiae, and increased muscle tone are not typical manifestations of hypoglycemia in newborns with a history of maternal gestational diabetes mellitus.
A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: Decreasing lighting levels helps reduce overstimulation, which can exacerbate symptoms of neonatal abstinence syndrome.
A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I can turn my baby's car seat around when she weighs 15 pounds.
- B. I can place my baby in the front seat with the airbag turned off.
- C. I will position my baby at a 45-degree angle in the car seat
- D. I will place my baby in a forward-facing car sees in my back seat.
Correct Answer: C
Rationale: Positioning the baby at a 45-degree angle in the car seat ensures proper airway alignment and safety. Turning the car seat around or placing the baby in the front seat is unsafe.