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A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse Include in the teaching?
- A. This test will be repeated when your baby is 2 months old.
- B. A nurse will draw blood from your baby's inner elbow.
- C. This test should be performed after your baby is 24 hours old.
- D. Your baby will be given 2 ounces of water to drink prior to the test.
Correct Answer: C
Rationale: Rationale: The correct answer is C because newborn genetic screening should be performed after the baby is 24 hours old to ensure accurate results. Testing too early may lead to false negatives. Choice A is incorrect because the test is typically done once soon after birth. Choice B is incorrect as blood is usually drawn from the baby's heel, not inner elbow. Choice D is incorrect as newborns should not be given water before the test due to risk of aspiration.
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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring proper identification is crucial for providing safe and effective care. By verifying the newborn's identification, the nurse can confirm they are caring for the right baby, preventing any potential errors in treatment or medication administration. This step is essential in maintaining patient safety and preventing harm.
Confirming the Apgar score (choice A) can be important but is not the first priority in this scenario. Administering vitamin K (choice C) is a routine procedure but can be done after verifying identification. Determining obstetrical risk factors (choice D) is important for overall assessment but is not the immediate priority.
A nurse is reviewing the provider's prescription in the adolescent's medical chart
Exhibit 1
History and Physical, Adolescent is sexually active with two current partners.
IUD in place, Reports not using condoms during sexual activity.
History of type 1 diabetes mellitus
Which of the following indicates whether the adolescent understands the teaching on requires further education?
- A. I should continue taking all my medications even if I don't show any symptoms.
- B. If I continue to get this type of infection, it can affect my ability to have kids in the future.
- C. I should go to the emergency department if my urine turns dark.
- D. As long as I keep my IUD, I don't need to use condoms.
- E. I'm more likely to get a sunburn while taking these medications.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. Choice D states, "As long as I keep my IUD, I don't need to use condoms." This statement indicates a misunderstanding as IUDs do not protect against sexually transmitted infections .
2. This statement shows a lack of understanding regarding the importance of using condoms to prevent STIs.
3. Therefore, selecting Choice D indicates that further education is required to clarify the misconception about the role of IUDs in STI prevention.
Summary:
- Choice A is correct as it indicates a misunderstanding about the necessity of taking medications regardless of symptoms.
- Choice B is correct as it states a potential consequence of untreated infections, showing understanding.
- Choice C is correct as it highlights a symptom that warrants immediate medical attention.
- Choice E is incorrect as it does not pertain to the understanding of contraception and STI prevention.
- Choices F and G are not applicable and can be disregarded.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: The correct answer is C. Continuing to take insulin even if experiencing nausea and vomiting is crucial in managing blood glucose levels in type 1 diabetes during pregnancy. Nausea and vomiting can lead to decreased food intake, potentially causing hypoglycemia if insulin is not adjusted. Increasing insulin doses in the first trimester (choice A) is not recommended without healthcare provider guidance. Engaging in moderate exercise with high blood glucose (choice B) could worsen hyperglycemia. Ensuring a bedtime snack high in refined sugar (choice D) may lead to unstable blood glucose levels.
A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
- A. Identify the attitude of the head.
- B. Palpate the fundus to identify the fetal part.
- C. Determine the location of the fetal back.
- D. Palpate for the fetal part presenting at the inlet.
Correct Answer: B, C, D, A
Rationale: The correct order for performing Leopold maneuvers is B, C, D, A. Firstly, palpating the fundus (B) helps identify the fetal part. Next, determining the location of the fetal back (C) gives insight into the baby's position. Palpating for the fetal part at the inlet (D) helps determine the presenting part. Finally, identifying the attitude of the head (A) concludes the assessment. The other choices do not align with the sequential nature of Leopold maneuvers, making them incorrect.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing respiratory depression and cardiac arrest. Calcium gluconate is the antidote for magnesium toxicity, so having it readily available is crucial for immediate administration if toxicity occurs. Option A is incorrect as fluid intake should not be restricted in preeclampsia. Option C is incorrect as deep tendon reflexes should be assessed more frequently (every 1-2 hours) due to the risk of hypermagnesemia. Option D is incorrect as intake and output should be monitored hourly to detect any changes in renal function.