Nokea
A preterm neonate is unable to breast- or bottle-feed. The physician writes an order to feed the neonate via nasogastric (NG) tube. When choosing an NG feeding tube for a neonate, the nurse should base the tube size on the neonate's:
- A. Disease process.
- B. Gestational age.
- C. Length.
- D. Weight.
Correct Answer: B
Rationale: Gestational age determines the appropriate NG tube size, as it correlates with the neonate's anatomical development.
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The nurse is planning care for a multigravid client hospitalized at 36 weeks' gestation with confirmed rupture of membranes and no evidence of labor. Which of the following would the nurse expect the physician to order?
- A. Frequent assessments of cervical dilation.
- B. Intravenous oxytocin administration.
- C. Vaginal culture for Neisseria gonorrhoeae.
- D. Sonogram for amniotic fluid volume index.
Correct Answer: C
Rationale: Vaginal cultures help identify infections after membrane rupture.
The nurse is caring for a primigravid client in active labor at 42 weeks' gestation. The client has had no analgesia or anesthesia and has been pushing for 2 hours. The nurse can be most helpful to this client by:
- A. Changing her pushing position every 15 minutes.
- B. Notifying the health care provider of her current status.
- C. Continuing with current pushing technique.
- D. Assessing the client's current pain and fetal status.
Correct Answer: D
Rationale: Prolonged pushing (2 hours) in a primigravid client at 42 weeks requires assessment of pain and fetal status to identify potential complications like exhaustion or fetal distress. Changing positions may help but is less urgent, notifying the provider is premature without assessment, and continuing the current technique may not address underlying issues.
The nurse is reviewing the chart of a multigravid client at 39 weeks' gestation with suspected HELLP syndrome. The nurse should notify the health care provider about which of the following test results?
- A. Platelets 200,000 mm3.
- B. Lactate dehydrogenase(LDH)> 200 units/L.
- C. Uric acid 3 mg/dL.
- D. Aspartate aminotransferase(AST) 15 units/L.
Correct Answer: B
Rationale: Elevated LDH indicates possible hemolysis in HELLP syndrome.
A client has just had a cesarean section for a prolapsed cord. In reviewing the client's history, which of the following factors places a client at risk for cord prolapse? Select all that apply.
- A. -2 station.
- B. Low birth weight infant.
- C. Rupture of membranes.
- D. Breech presentation.
- E. Prior abortion.
- F. Low lying placenta.
Correct Answer: A,B,C,D,F
Rationale: These factors increase the risk of cord prolapse.
The physician orders scalp stimulation of the fetal head for a primigravid client in active labor. When explaining to the client about this procedure, which of the following would the nurse include as the purpose?
- A. Assessment of the fetal hematocrit level.
- B. Increase in the strength of the contractions.
- C. Increase in the fetal heart rate and variability.
- D. Assessment of fetal position.
Correct Answer: C
Rationale: Scalp stimulation is used to assess fetal well-being by eliciting a heart rate acceleration, indicating good oxygenation and variability. It does not assess hematocrit, strengthen contractions, or determine position.