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A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: The correct answer is D: You should press the handheld button when you feel your baby move. In a nonstress test, the client is required to press a handheld button whenever they feel the baby move. This action helps to correlate fetal movements with changes in the fetal heart rate, allowing healthcare providers to assess the baby's well-being. This active participation from the client ensures accurate monitoring of the baby's condition. The other choices are incorrect because: A: The duration of a nonstress test can vary but typically takes around 20-40 minutes. B: Lying in a supine position is not recommended during pregnancy as it can decrease blood flow to the baby. C: It is important for the client to have a light meal before the test to ensure the baby is active during monitoring.
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A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?
- A. Shortness of breath when climbing stairs
- B. Swelling of feet and ankles at the end of the day
- C. Headache that is unrelieved by analgesia
- D. Braxton Hicks contractions
Correct Answer: C
Rationale: The correct answer is C: Headache that is unrelieved by analgesia. This symptom could indicate preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Prompt reporting is crucial to prevent complications. Shortness of breath (A) and swelling of feet and ankles (B) are common in pregnancy but not necessarily indicative of a serious complication. Braxton Hicks contractions (D) are normal and not usually a cause for concern.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
A nurse is caring for a newborn who is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Decrease the lighting levels in the nursery.
- B. Wrap the newborn loosely in a blanket.
- C. Provide frequent stimulation for the newborn.
- D. Encourage frequent eye contact with the newborn during feedings
Correct Answer: A
Rationale: The correct answer is A: Decrease the lighting levels in the nursery. Neonatal abstinence syndrome causes sensitivity to stimuli, including light. By decreasing lighting levels, the nurse can help reduce overstimulation and promote a calm environment for the newborn. This can aid in soothing the baby and decreasing symptoms associated with the syndrome.
Choice B is incorrect because wrapping the newborn loosely in a blanket may not directly address the sensitivity to light and other stimuli. Choice C, providing frequent stimulation, would likely exacerbate the symptoms of neonatal abstinence syndrome due to the increased sensory input. Choice D, encouraging frequent eye contact during feedings, could also lead to overstimulation for the newborn.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks gestation with a positive contraction stress test, the client may be at risk for uteroplacental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, tone, breathing, amniotic fluid volume, and fetal heart rate reactivity. This test helps determine if the fetus is getting enough oxygen and nutrients. Preparing the client for a BPP is crucial in monitoring the fetal status and making decisions regarding further management.
Incorrect choices:
A: Percutaneous umbilical blood sampling is an invasive procedure used to evaluate fetal blood gases and acid-base status, typically performed when there are concerns about fetal well-being like severe growth restriction or Rh incompatibility.
B: Amnioinfusion is the infusion of fluid into the amniotic cavity and is used to correct oligohydramnios (low amniotic fluid volume).
D: Chorionic villus
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for proper identification and prevention of mix-ups. Matching the identification bands ensures that the newborn is going to the correct parent, enhancing safety.
Choice B is incorrect because asking the parent to verify their own information does not confirm the identification of the newborn. Choice C is incorrect as it focuses on the security tag number, which may not be as reliable as the identification bands. Choice D is incorrect as matching the date and time of birth to the parent's medical record does not provide direct confirmation of the parent-newborn match.