Nokea
A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following?
- A. Humidify the air being delivered.
- B. Cover the neonate's scalp with a warm cap.
- C. Record the neonate's temperature every 3 to 4 minutes.
- D. Assess the neonate's blood glucose level.
Correct Answer: A
Rationale: Humidifying the air prevents drying of the mucous membranes and maintains airway moisture, which is critical for preterm neonates.
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The physician orders oxytocin to be added to the intravenous fluids of a 30-year-old multigravid client at 37 weeks' gestation with twins after vaginal delivery. The nurse should administer the oxytocin after delivery of which of the following?
- A. First placenta.
- B. First twin.
- C. Second placenta.
- D. Second twin.
Correct Answer: C
Rationale: Oxytocin is administered post-delivery of both twins and placentas to promote uterine contraction and prevent postpartum hemorrhage. Administering earlier risks complications with the second twin or placentas.
A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth(NPO) status and is receiving intravenous(IV) fluid replacement therapy. In planning this client's care, the nurse should collaborate with the health care provider(HCP) to carry out which of the following?
- A. Withhold oral fluids indefinitely until acidosis is corrected.
- B. Give oral fluids in small quantities whenever the client desires.
- C. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.
- D. Withhold oral fluids until total parenteral nutrition replaces lost electrolytes.
Correct Answer: C
Rationale: Gradual reintroduction of oral fluids is appropriate once vomiting subsides.
A nurse is counseling a client about the use of a diaphragm. Which of the following client statements indicates a need for further teaching?
- A. I need to use spermicide with the diaphragm.
- B. I can insert the diaphragm up to 6 hours before intercourse.
- C. I should leave the diaphragm in place for at least 6 hours after intercourse.
- D. I can reuse the diaphragm without cleaning it.
Correct Answer: D
Rationale: The diaphragm must be cleaned after each use to maintain hygiene and effectiveness. The other statements are correct, indicating a need for further teaching about cleaning.
A 24-year-old primigravid client in active labor requests use of the jet hydrotherapy tub to aid in pain relief. The nurse bases the response on the understanding that this therapy is commonly contraindicated for clients with which of the following?
- A. A required membranes.
- B. Multifetal gestation.
- C. Diabetes mellitus.
- D. Hypotonic labor patterns.
Correct Answer: A
Rationale: Jet hydrotherapy (e.g., whirlpool tubs) is contraindicated with ruptured membranes due to the risk of infection from water entering the vaginal canal. Multifetal gestation, diabetes, and hypotonic labor are not absolute contraindications unless other complications are present.
While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?
- A. Bronze-colored skin.
- B. Maculopapular chest rash.
- C. Urine specific gravity of 1.018.
- D. Absent Moro reflex.
Correct Answer: A
Rationale: Bronze-colored skin is a potential complication of phototherapy and should be reported to the health care provider.