Nokea
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.
You may also like to solve these questions
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
- A. Ask the healthcare provider to prescribe a nonsteroidal anti-inflammatory drug (NSAID)
- B. Have one of the parents hold the baby
- C. Perform guided imagery
- D. Consult a child life specialist
- E. Encourage the baby's mother to breastfeed the baby
- F. Wait 1 hour, reassess, and give medication if the FLACC score remains elevated
- G. Request a prescription for an opioid
Correct Answer: B,D,G
Rationale: NSAIDs, parental holding, child life consultation, and opioids (if severe) are appropriate. Guided imagery is too advanced, breastfeeding is contraindicated (NPO), and delaying treatment is inappropriate.
The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. Which priority issue should the nurse address to ensure the newborn's survival?
- A. Heat loss.
- B. Fluid balance.
- C. Bleeding tendencies.
- D. Hypoglycemia.
Correct Answer: A
Rationale: Preventing heat loss avoids cold stress, which can lead to respiratory distress and metabolic issues, critical for newborn survival.
Upon completion of a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse prepares the family for discharge. Which information should the nurse include?
- A. Administer antipyretic medication on a continuous basis.
- B. Continue strict monitoring of daily wet diapers for 1 week.
- C. Have the antibiotic trough level drawn within 3 days.
- D. Monitor the infant for response to auditory stimuli.
Correct Answer: D
Rationale: Monitoring auditory responses detects hearing loss, a common meningitis complication, requiring follow-up screening.
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which pain scales would be appropriate for this client? Select all that apply.
- A. FLACC Postoperative Pain Scale
- B. Riley Infant Pain Scale
- C. Poker Chip Tool
- D. Visual Analog Scale
- E. Numeric
- F. FACES
Correct Answer: A,B
Rationale: FLACC and Riley Infant Pain Scales assess behavioral cues in nonverbal infants, suitable for a 4-month-old post-surgery. Other scales require cognitive abilities beyond this age.
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.