Nokea
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I should increase my protein intake to 60 grams each day."
- B. "I should drink 2 liters of water each day."
- C. "I should increase my overall daily caloric intake by 300 calories."
- D. "I should take 600 micrograms of folic acid each day."
Correct Answer: A
Rationale: Increasing protein intake to 60 grams daily is essential during pregnancy to support fetal growth and maternal tissue expansion. This aligns with nutritional guidelines for pregnancy.
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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, to administer the injection into the vastus lateralis muscle. In newborns, the vastus lateralis muscle is the recommended site for intramuscular injections due to its larger muscle mass and reduced risk of injury to nerves or blood vessels. This site is typically used for vaccines in infants to ensure proper absorption and minimize discomfort. Option B is incorrect as massaging the site can lead to discomfort or tissue damage. Option C is incorrect as inserting the needle at a 45° angle is not necessary for intramuscular injections in newborns. Option D is incorrect as a smaller gauge needle is usually recommended for newborns to reduce pain and tissue trauma.
Which of the following is a potential complication of a nuchal cord?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Amniotic fluid embolism
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A: Fetal distress. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck. This can potentially lead to decreased blood flow and oxygen supply to the baby, resulting in fetal distress. Maternal hemorrhage and amniotic fluid embolism are not direct complications of a nuchal cord. Therefore, the correct answer is A as it directly relates to the potential consequence of a nuchal cord.
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: Newborn genetic screening is typically performed after 24 hours of birth to ensure accurate results and allow time for metabolic processes to stabilize.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: Maintaining the client on bed rest helps prevent the dislodgement of a thrombus, which could lead to a pulmonary embolism, a life-threatening complication.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: Jaundice within the first 24 hours of life is considered pathological and should be reported to the provider, as it may indicate hemolytic disease or other serious conditions.