Nokea
A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?
- A. I should empty my bladder before the procedure.
- B. I will be lying on my side during the procedure.
- C. I will be asleep during the procedure.
- D. I should start fasting 24 hours before the procedure.
Correct Answer: A
Rationale: The correct answer is A: "I should empty my bladder before the procedure." This statement indicates understanding because a full bladder can obstruct visualization during the amniocentesis. Choice B is incorrect because the client should be lying flat on their back during the procedure. Choice C is incorrect as local anesthesia is typically used, and the client is awake. Choice D is incorrect as fasting is not required for an amniocentesis.
You may also like to solve these questions
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?
- A. Check the client's temperature.
- B. Observe for uterine contractions.
- C. Administer Rho(D) immune globulin.
- D. Monitor the FHR.
Correct Answer: C
Rationale: The correct answer is C: Administer Rho(D) immune globulin. This is the priority intervention following an amniocentesis in an Rh-negative client at 15 weeks gestation to prevent Rh isoimmunization. Administering Rho(D) immune globulin helps prevent the mother's immune system from forming antibodies against Rh-positive fetal blood cells, which could lead to hemolytic disease in the newborn. Checking the client's temperature (A) is not the priority as there is no immediate risk related to the procedure. Observing for uterine contractions (B) is important but not the priority immediately post-procedure. Monitoring the FHR (D) is important but not the priority at this time.
A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?
- A. Administer the injection into the vastus lateralis muscle.
- B. Vigorously massage the site following the injection.
- C. Insert the needle at a 45° angle for injection.
- D. Use a 21-gauge needle for the injection.
Correct Answer: A
Rationale: The correct answer is A: Administer the injection into the vastus lateralis muscle. This is the recommended site for administering vaccines to newborns due to the large muscle mass, reducing the risk of injury to nerves and blood vessels. It also allows for proper absorption of the vaccine. Option B is incorrect as vigorous massage can lead to tissue damage and discomfort. Option C is incorrect as the needle should be inserted at a 90° angle for intramuscular injections. Option D is incorrect as a smaller gauge needle (typically 25-27 gauge) is recommended for newborns to minimize pain and tissue trauma.
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 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: Correct Answer: C - Initiate seizure precautions.
Rationale: Infants with neonatal abstinence syndrome are at risk for seizures due to drug withdrawal. Initiating seizure precautions involves creating a safe environment to prevent injury during a seizure. This includes padding the crib, ensuring a clear space around the infant, and having emergency medications available. Monitoring blood glucose levels every hour (A) is not directly related to neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a basic positioning technique and does not address the specific needs of a baby with neonatal abstinence syndrome. Providing a stimulating environment (D) is contraindicated as it can exacerbate symptoms of withdrawal in the infant.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways
- B. Places the newborn in the crib in a prone position
- C. Offers the newborn a pacifier dipped in formula
- D. Prepares a bottle of formula mixed with rice cereal
Correct Answer: A
Rationale: The correct answer is A because laying the newborn across the lap and gently swaying helps provide comfort and bonding, mimicking the soothing motion in the womb. This action promotes a secure attachment between the guardian and the newborn. Placing the newborn in a crib in a prone position (B) is unsafe and increases the risk of sudden infant death syndrome (SIDS). Offering a pacifier dipped in formula (C) can introduce unnecessary calories and increase the risk of overfeeding. Preparing a bottle of formula mixed with rice cereal (D) is not appropriate for a newborn and can lead to digestive issues.