Nokea
A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread
- B. A sliced apple and red grapes
- C. A chocolate chip cookie with a glass of skim milk
- D. A scrambled egg with cheddar cheese
Correct Answer: B
Rationale: Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. A sliced apple and red grapes are low in phenylalanine, making them safe choices.
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Which of the following characteristics would indicate true labor in a client?
- A. Contractions are irregular and painless
- B. Fetus moves to an anterior position
- C. Bloody show is not present
- D. Contractions are regular in frequency
Correct Answer: D
Rationale: True labor is characterized by regular contractions that increase in intensity and frequency. These contractions result in cervical dilation and effacement, indicating the onset of labor.
A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion
- B. Administer oxygen at 10 L/min via nonrebreather face mask
- C. Discontinue the infusion of oxytocin
- D. Place the client in a left lateral position
Correct Answer: C
Rationale: The first action should be to discontinue the infusion of oxytocin, as it can contribute to uterine hyperstimulation and fetal distress. This allows for immediate assessment and management of the fetal heart rate.
A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest thrusts
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct Answer: C
Rationale: If routine suctioning with a bulb syringe is ineffective, the next step is to use mechanical suction. This ensures that any obstruction in the airway is cleared. If the newborn's condition does not improve, chest compressions or further interventions may be needed.
A nurse is assessing a newborn who is 10 hr old. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 36.5° C (97.7° F)
- B. Nasal flaring
- C. Heart rate 158/min
- D. One void since birth
Correct Answer: B
Rationale: Nasal flaring can indicate respiratory distress and should be reported immediately for further evaluation.
To decrease the incidence of sudden infant death syndrome (SIDS), the parents will position the newborn in a:
- A. Prone position
- B. Supine position
- C. Side-lying position
- D. Semi-fowler's position
Correct Answer: B
Rationale: The safest sleeping position for infants is on their back (supine position). This reduces the risk of sudden infant death syndrome (SIDS), as sleeping in other positions can increase the risk of airway obstruction.