Nokea
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: The car seat should remain rear-facing until at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant's head, neck, and spine.
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A nurse is caring for a client who is 36 weeks pregnant and reports leaking fluid. Which of the following tests should the nurse use to confirm that the client¢â‚¬â„¢s membranes have ruptured?
- A. Nonstress test
- B. Biophysical profile
- C. Fern test
- D. Amniocentesis
Correct Answer: C
Rationale: The fern test is used to confirm rupture of membranes. A sample of vaginal fluid is examined under a microscope, and the presence of a fern-like pattern indicates the presence of amniotic fluid.
A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding.
A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Hypertonia
- B. Jitteriness
- C. Acrocyanosis
- D. Generalized petechiae
Correct Answer: B
Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy.
A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1° C (96.9° F)
- D. Excessive sleeping
Correct Answer: B
Rationale: Moderate tremors of the extremities are a common sign of opioid withdrawal in newborns. Other signs may include irritability, feeding difficulties, and gastrointestinal disturbances.
A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
- A. Vitamin E
- B. Vitamin D
- C. Fiber
- D. Calcium
Correct Answer: D
Rationale: Calcium is vital during pregnancy for fetal bone development and to prevent maternal bone loss. The recommended daily intake should be increased to support these needs.