Nokea
A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy?
- A. It is initiated when the bilirubin level reaches 5 mg/dL.
- B. It converts bilirubin to a water-soluble form to be excreted in the urine.
- C. It changes bilirubin to a bile salt to be excreted through the bowel.
- D. It requires eye patches to remain in place 24 hours a day.
Correct Answer: B
Rationale: Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys. It is initiated when the bilirubin level reaches 12 to 15 mg/dL. The eye patches are worn during therapy, but removed for feeding, bathing, and socialization.
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A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem?
- A. Calcium deficit
- B. Cephalopelvic disproportion
- C. Bleeding tendency
- D. Low hemoglobin levels
Correct Answer: B
Rationale: There are several physiologic concerns for pregnant adolescents, including cephalopelvic disproportion.
The patient who has taken the ovulation stimulant clomiphene (Clomid) and who has been determined to be pregnant calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a ___.
Correct Answer: mole
Rationale: Hydatidiform moles occur frequently in people who have taken Clomid. The physical changes are similar to a real pregnancy until bleeding occurs and some grapelike clusters are passed.
What is the antidote for magnesium sulfate toxicity?
- A. Vitamin K
- B. Calcium gluconate
- C. Potassium sulfate
- D. Calcium carbonate
Correct Answer: B
Rationale: The antidote for magnesium sulfate toxicity is calcium gluconate.
The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth?
- A. Within normal limits
- B. Pathologic
- C. A result of iron deficiency
- D. Indicating possible hepatitis
Correct Answer: B
Rationale: Jaundice observed at birth is considered an indicator of a pathologic condition, erythroblastosis fetalis. It is considered abnormal.
What symptom no matter what stage of pregnancy should be reported immediately?
- A. Backache
- B. Urinary frequency
- C. Vaginal bleeding
- D. Uterine tightening
Correct Answer: C
Rationale: Women should be instructed to contact their health care provider if any bleeding occurs during pregnancy.