Nokea
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Transmission can occur via the saliva and urine of the newborn
- B. This infection requires that airborne precautions be initiated for the newborn
- C. Mothers will receive prophylactic treatment with acyclovir prior to delivery
- D. Lesions are visible on the mother's genitalia
Correct Answer: A
Rationale: CMV transmission occurs through newborn saliva and urine, unlike requiring airborne precautions, acyclovir (herpes treatment), or visible genital lesions (not typical).
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A nurse is caring for a client who has pregestational diabetes mellitus. Which of the following clinical findings should indicate to the nurse that the client has hyperglycemia?
- A. Dizziness
- B. Increased urination
- C. Double vision
- D. Sweating
Correct Answer: B
Rationale: Increased urination (polyuria) is a hallmark of hyperglycemia as the body excretes excess glucose, unlike dizziness, double vision, or sweating (more hypoglycemic symptoms).
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the client to stop taking the antiretroviral medications at 32 weeks of gestation.
- B. Use a fetal scalp electrode during labor and delivery.
- C. Bathe the newborn before initiating skin-to-skin contact.
- D. Administer a pneumococcal immunization to the newborn within 4 hr following birth.
Correct Answer: C
Rationale: Bathing the newborn removes maternal fluids, reducing HIV transmission risk, unlike stopping antiretrovirals (continued), scalp electrodes (increase risk), or pneumococcal vaccine (not routine).
A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Offer to take the newborn to the nursery to finish his feeding
- B. Insist that the mother pick up the newborn to feed him
- C. Demonstrate how to hold the newborn and allow the client to practice
- D. Persuade the client to breastfeed the newborn to promote bonding
Correct Answer: C
Rationale: Demonstrating safe holding respects the client's concerns while promoting bonding, unlike nursery removal, insistence, or pushing breastfeeding.
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
- A. I won't apply perfumed lotion to my abdomen before the test.
- B. I can't have anything to eat after midnight.
- C. I need to take a stool softener the night before the test.
- D. I will drink water before the test until my bladder feels full.
Correct Answer: D
Rationale: A full bladder enhances ultrasound visibility by displacing intestines, unlike avoiding lotion, fasting, or stool softeners, which are not required.
A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Monitor the rectal temperature every 4 hr
- B. Administer broad-spectrum antibiotics
- C. Cleanse the site with povidone-iodine
- D. Prepare for surgical closure after 72 hr
Correct Answer: B
Rationale: Broad-spectrum antibiotics prevent meningitis from CSF leakage, unlike rectal temperature (contraindicated), povidone-iodine (neurotoxic), or delayed surgery (urgent within 24-48 hours).