Nokea
Assessment of a 2-day-old neonate delivered at 34 weeks' gestation reveals absent apical pulse left of the midclavicular line, cyanosis, grunting, and diminished breath sounds. The nurse should first:
- A. Consult with health care provider to obtain a chest x-ray.
- B. Reposition the neonate and then assess if the grunting and cyanosis resolve.
- C. Begin oxygen administration at 6-8 L via mask.
- D. Obtain a complete blood count to determine infection.
Correct Answer: A
Rationale: These symptoms suggest a serious condition like dextrocardia or pneumothorax, and consulting for a chest x-ray is the priority to confirm the diagnosis.
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When caring for a neonate diagnosed with gastroschisis, which of the following actions should the nurse record to do first?
- A. Weigh the neonate.
- B. Insert an orogastric tube.
- C. Prepare for immediate blood transfusion.
- D. Cover the abdomen with a moistened sterile gauze.
Correct Answer: D
Rationale: Covering the abdomen with moistened sterile gauze prevents infection and dehydration of the exposed intestines, which is the first priority.
A client with gestational diabetes who is entering her third trimester is learning how to monitor her fetus's movements. After teaching the client about the kick count, the nurse should provide further instruction if the client makes which of the following statements?
- A. "The baby may be more active at different times of the day."
- B. "How I feel my baby move is different than my friend."
- C. "The baby should be moving less than 10 times in 3 hours."
- D. "The baby may not move at times because it is asleep."
Correct Answer: C
Rationale: The baby should move at least 10 times in 2 hours.
The physician orders an amniocentesis for a primigravid client at 35 weeks' gestation in early labor to determine fetal lung maturity. Which of the following is an indicator of fetal lung maturity?
- A. A amount of bilirubin present.
- B. Presence of red blood cells.
- C. Barr body determination.
- D. Lecithin-sphingomyelin (L/S ratio).
Correct Answer: D
Rationale: The lecithin-sphingomyelin (L/S) ratio in amniotic fluid is a key indicator of fetal lung maturity, with a ratio of 2:1 or higher indicating mature lungs. Bilirubin, red blood cells, and Barr body determination are not used for this purpose.
A 38-year-old client at about 14 weeks' gestation is admitted to the hospital with a diagnosis of complete hydatidiform mole. Soon after admission, the nurse would assess the client for signs and symptoms of which of the following?
- A. Pregnancy-induced hypertension.
- B. Gestational diabetes.
- C. Hypothyroidism.
- D. Polycythemia.
Correct Answer: A
Rationale: Pregnancy-induced hypertension is a common complication of hydatidiform mole.
A nurse is teaching a client about the use of the vaginal contraceptive ring. Which of the following instructions should the nurse include?
- A. Insert a new ring daily.
- B. Leave the ring in place for 3 weeks, then remove for 1 week.
- C. Apply the ring to the vaginal wall.
- D. Replace the ring every 6 months.
Correct Answer: B
Rationale: The vaginal contraceptive ring is left in place for 3 weeks, then removed for 1 week to allow a withdrawal bleed. It is not inserted daily, applied to the vaginal wall (it sits in the vagina), or replaced every 6 months (it's monthly).