Nokea
Approximately 90 minutes after birth, the nurse should encourage the mother of a term neonate to do which of the following?
- A. Feed the neonate.
- B. Allow the neonate to sleep.
- C. Get to know the neonate.
- D. Change the neonate's diaper.
Correct Answer: A
Rationale: Feeding within 90 minutes promotes bonding, stabilizes blood glucose, and initiates breastfeeding or formula feeding.
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A multigravid client is admitted to the hospital with a diagnosis of ectopic pregnancy. The nurse anticipates that, because the client's fallopian tube has not yet ruptured, which of the following may be ordered?
- A. Progestin contraceptives(Hylutin).
- B. Medroxyprogesterone(Depo-Provera).
- C. Methotrexate.
- D. Dyphylline(Dilor).
Correct Answer: C
Rationale: Methotrexate is used to treat unruptured ectopic pregnancies.
A nurse is discussing the benefits of the copper IUD with a client. Which of the following statements by the nurse is accurate?
- A. The copper IUD can reduce menstrual bleeding.
- B. The copper IUD is effective for up to 10 years.
- C. The copper IUD requires daily monitoring.
- D. The copper IUD prevents ovulation.
Correct Answer: B
Rationale: The copper IUD is effective for up to 10 years, providing long-term contraception. It may increase menstrual bleeding, does not require daily monitoring, and does not prevent ovulation, working primarily by affecting sperm motility.
A primigravid client in active labor with a fetus in LOP position complains of severe back pressure. Which of the following would be the priority nursing diagnosis for this client?
- A. Anxiety related to fear of maternal-fetal outcomes.
- B. Ineffective coping related to lack of experience in labor.
- C. Urinary retention related to prolonged labor process.
- D. Pain related to occipitoposterior position and prolonged fetal descent.
Correct Answer: D
Rationale: Severe back pain due to the LOP position is a priority, as it impacts the client's comfort and labor experience. Pain management (e.g., counterpressure) is critical. Anxiety, coping, and urinary retention are secondary concerns.
A preterm infant delivered 2 hours ago at 34 weeks' gestation is experiencing rapid respirations, grunting, no breath sounds on one side, and a shift in location of heart sounds. The nurse should prepare to assist with which of the following?
- A. Placement of the neonate on a ventilator.
- B. Administration of bronchodilators through the nurse.
- C. Suctioning of the neonate's nares with wall suction.
- D. Insertion of a chest tube into the neonate.
Correct Answer: D
Rationale: These symptoms suggest a pneumothorax, and inserting a chest tube is the priority to relieve air trapping.
When caring for a multigravid client admitted to the hospital with vaginal bleeding at 38 weeks' gestation, which of the following would the nurse anticipate administering intravenously if the client develops disseminated intravascular coagulation(DIC)?
- A. Ringer's lactate solution.
- B. Fresh frozen platelets.
- C. 5% dextrose solution.
- D. Warfarin sodium(Coumadin).
Correct Answer: B
Rationale: Fresh frozen platelets are used to manage bleeding in DIC.