Nokea
After teaching the multiparous mother about hemolytic disease of the newborn and Rh sensitization, the nurse determines that the client understands why she was not sensitized during her other pregnancy when she says which of the following?
- A. My other baby had a different father.'
- B. Like most women, I have immunity against the Rh factor.'
- C. Antibodies are not usually formed until after exposure to an antigen.'
- D. My blood couldn't neutralize antibodies formed from my first pregnancy.'
Correct Answer: C
Rationale: Antibodies form after exposure to an Rh-positive fetus, typically not during the first pregnancy, explaining why sensitization did not occur previously.
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The physician orders ampicillin The dose is 100 mg/kg per dose for a newly admitted neonate. The neonate weighs 1,350 grams. How many milligrams should the nurse administer?
- A. mg.
Correct Answer: B
Rationale: The neonate weighs 1,350 g (1.35 kg). The dose is 100 mg/kg, so 100 mg/kg × 1.35 kg = 135 mg. The nurse should administer 135 mg.
The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients first?
- A. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes.
- B. A newborn delivered at 36-weeks' gestation weighing $5 \mathrm{lb}$ who is due to breast-feed for the first time in 15 minutes.
- C. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago.
- D. A newborn who had a borderline low temperature and was double-wrapped with a hat on ½ hour ago to bring up the temperature.
Correct Answer: C
Rationale: A respiratory rate of 62 is elevated and may indicate respiratory distress, requiring immediate assessment.
A 28-year-old multigravid client at 28 weeks' gestation diagnosed with acute pyelonephritis is receiving intravenous fluids and antibiotics. After teaching the client about the rationale for the aggressive therapy, the nurse determines that the client needs further instruction when she says that acute pyelonephritis can lead to which of the following?
- A. Preterm labor.
- B. Maternal sepsis.
- C. Intrauterine growth retardation.
- D. Congenital fetal anomalies.
Correct Answer: D
Rationale: Acute pyelonephritis can cause preterm labor, maternal sepsis, and intrauterine growth retardation due to infection and inflammation. Congenital fetal anomalies are not a direct consequence, indicating a need for further teaching.
A primiparous client, 4 hours postpartum, reports feeling overwhelmed and anxious about caring for her newborn. Which nursing intervention is most appropriate?
- A. Encourage the client to rest and limit visitors.
- B. Teach the client basic newborn care skills immediately.
- C. Administer an anxiolytic medication as prescribed.
- D. Refer the client to a social worker for counseling.
Correct Answer: B
Rationale: Teaching basic newborn care skills empowers the client, reduces anxiety, and promotes confidence in the early postpartum period.
In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation?
- A. Taking in.
- B. Taking on.
- C. Taking hold.
- D. Letting go.
Correct Answer: C
Rationale: The 'taking hold' phase is characterized by the mother becoming more active, showing interest in caring for the infant, and asking questions about infant care, as described in the scenario.