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A nurse is providing teaching to a client who has mild preeclampsia and will be caring for herself at home during the last 2months of pregnancy. This of the following statements by the client indicates an understanding of the teaching.
- A. “I will count baby’s lacks every other day.
- B. “I will alternate the arm use to check my blood pressure
- C. I will check my urine for protein daily
- D. I will consume 50 grams of protein daily
Correct Answer: C
Rationale: The correct answer is C: "I will check my urine for protein daily." This is the correct answer because monitoring urine for protein is crucial in managing preeclampsia. Proteinuria is a key marker for worsening preeclampsia as it indicates kidney damage. By checking urine daily, the client can detect early signs of deterioration and seek medical help promptly.
Answers A, B, and D are incorrect because they do not directly relate to monitoring preeclampsia. Counting baby's kicks (A) and alternating arm use for blood pressure checks (B) are important but not as critical as monitoring proteinuria. Consuming 50 grams of protein daily (D) is beneficial for overall health during pregnancy but does not specifically address the management of preeclampsia.
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A nurse is caring for a client who has a complete uterine rupture. Which of the following findings should the nurse expect?
- A. Early fetal heart rate decelerations
- B. Hypotension
- C. Painless, dark red vaginal bleeding
- D. bounding peripheral pulses
Correct Answer: B
Rationale: The correct answer is B: Hypotension. A complete uterine rupture is a serious complication where the uterine wall tears completely, leading to massive internal bleeding. This can result in hypotension due to blood loss. Early fetal heart rate decelerations (choice A) are not indicative of uterine rupture. Painless, dark red vaginal bleeding (choice C) is more commonly associated with placental abruption. Bounding peripheral pulses (choice D) are not a typical finding in uterine rupture.
A nurse is caring for newborn who is 1 hr old and has a respiratory rate of 50/min, a heart rate of 130/min, and an auxiliary temperature of 36.1*C (97F). Which of the following actions should the nurse take?
- A. Give the newborn a warm bath.
- B. Apply a cap to the newborn head.
- C. Reposition the newborn.
- D. Obtain an oxygen saturation level
Correct Answer: B
Rationale: The correct answer is B: Apply a cap to the newborn's head. This action helps prevent heat loss through the newborn's head, which is a common area for heat loss in newborns. The respiratory rate of 50/min and heart rate of 130/min are within normal ranges for a newborn. The temperature of 36.1°C (97°F) is slightly lower than the normal range, so keeping the newborn warm is important. Giving a warm bath (choice A) may further decrease the newborn's body temperature. Repositioning the newborn (choice C) may not address the issue of heat loss. Obtaining an oxygen saturation level (choice D) is not indicated based on the information provided. Therefore, applying a cap to the newborn's head is the most appropriate action to help maintain the newborn's body temperature and prevent heat loss.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
- A. Apply a thin layer lotion to the newborn's skin every 8 hours
- B. Dress the newborn in a thin layer of clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.
Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.
In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing any procedure that involves contact with bodily fluids or potentially infectious material, such as blood or bodily secretions. Umbilical cord care may involve cleaning the area, which can have potential exposure to bodily fluids. The other choices (A, B, C) do not involve direct contact with bodily fluids or infectious material, so gloves are not necessary for those procedures. It is important to maintain infection control practices to prevent the spread of infections in the healthcare setting.
A nurse is developing an educational program about hemolytic diseases in newborns for a group of newly licensed nurses. Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother is Rh positive, and the father is Rh negative
- B. The mother is Rh negative, and the father is Rh positive
- C. The mother and the father are both Rh positive
- D. The mother and the father are both Rh negative
Correct Answer: B
Rationale: The correct answer is B: The mother is Rh negative, and the father is Rh positive. Hemolytic disease in newborns is caused by Rh incompatibility, where the mother is Rh negative and the father is Rh positive. This leads to the mother developing antibodies against the Rh-positive fetal red blood cells, resulting in hemolysis in the fetus. The other choices are incorrect because Rh incompatibility occurs when the mother is Rh negative and the father is Rh positive, not when both parents are Rh positive (choice C) or both are Rh negative (choice D). This educational program should emphasize the importance of Rh factor compatibility in preventing hemolytic disease in newborns.