Nokea
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
The correct answer is to place the newborn skin to skin on the birthing parent's chest and encourage breastfeeding to address Cold stress, a potential condition the client is most likely experiencing. These actions help regulate the newborn's temperature and provide essential warmth and nutrition. Parameters to monitor would include temperature (to assess for hypothermia) and bilirubin level (to monitor for jaundice, a common issue in newborns). Monitoring these parameters will help the nurse assess the client's progress and ensure appropriate interventions are implemented.
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A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention. Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?
- A. You should take the medication within 72 hours following unprotected sexual intercourse.
- B. You should avoid taking this medication if you are on an oral contraceptive.
- C. If you don't start your period within 5 days of taking this medication, you will need a pregnancy test.
- D. One dose of this medication will prevent you from becoming pregnant for 14 days after taking it.
Correct Answer: A
Rationale: The correct answer is A: You should take the medication within 72 hours following unprotected sexual intercourse. Levonorgestrel is most effective when taken within 72 hours after unprotected sex to prevent pregnancy. This timing is crucial for its efficacy.
Choice B is incorrect because levonorgestrel can be used in combination with oral contraceptives if needed. Choice C is incorrect as the absence of a period does not always indicate pregnancy, and a pregnancy test may not be necessary. Choice D is incorrect because levonorgestrel is effective for a shorter duration, not 14 days.
A nurse in an antepartum clinic is providing weeks of gestation. Upon reviewing the following findings should the nurse report to the provider? (Click on the 'Exhibit' button for additional information about the client. There are three tabs that contain separate categories of data.)
- A. 1-hr glucose tolerance test
- B. Hematocrit
- C. Fundal height measurement
- D. Fetal heart rate (FHR)
Correct Answer: D
Rationale: The correct answer is D: Fetal heart rate (FHR). The nurse should report any abnormal findings related to fetal well-being to the provider. Monitoring the FHR is crucial to assess the baby's status and can indicate potential issues such as fetal distress. In this scenario, if the FHR is abnormal (e.g., too high or too low), it could signal a problem that needs immediate attention.
A: 1-hr glucose tolerance test - This is typically done to screen for gestational diabetes and is not directly related to fetal well-being.
B: Hematocrit - This measures the volume percentage of red blood cells in blood and is more related to maternal health.
C: Fundal height measurement - This assesses fetal growth and position, but abnormal findings may not require immediate provider notification unless significant deviations are noted.
In summary, the other choices are not as time-sensitive or directly indicative of fetal distress as the FHR, making D the correct answer in this context.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks of gestation, a positive contraction stress test indicates potential placental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, muscle tone, breathing, amniotic fluid volume, and heart rate reactivity. This test helps determine the need for immediate delivery.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood for genetic testing and not for assessing fetal well-being. Amnioinfusion (B) is used to increase amniotic fluid volume during labor and not for evaluating fetal well-being. Chorionic villus sampling (D) is an invasive prenatal diagnostic test for genetic abnormalities and not for assessing fetal well-being.