Nokea
Newborn
Complete the following sentence using the lists of options: The nurse should [option] intramuscular ceftriaxone [purpose].
- A. The nurse should prescribe intramuscular ceftriaxone to decrease the risk of ophthalmia neonatorum in a newborn.
- B. The nurse should identify ceftriaxone as a suitable medication for bacterial infections.
- C. The nurse should use intramuscular ceftriaxone to treat gonorrhea effectively.
- D. The nurse should select intramuscular ceftriaxone for prophylaxis against postpartum infections.
Correct Answer: A
Rationale: Intramuscular ceftriaxone is effective in preventing ophthalmia neonatorum, caused by Neisseria gonorrhoeae. This bacterial prophylaxis inhibits cell wall synthesis, reducing infection transmission from mother to newborn.
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Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy. What additional care should the nurse consider?
- A. Administering prophylactic antibiotics to prevent infection.
- B. Assessing for signs of jaundice in the newborn.
- C. Monitoring the client's vital signs for stability.
- D. Educating the client on breastfeeding techniques.
Correct Answer: B
Rationale: Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.
Client with fibrocystic breast changes experiencing breast discomfort during menstruation.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase your potassium intake.
- B. Increase your fluid intake to 3 liters per day.
- C. Refrain from consuming alcohol.
- D. Limit your daily intake of fiber.
Correct Answer: C
Rationale: Alcohol consumption can worsen fibrocystic breast discomfort due to its estrogen-modulating effects, which may exacerbate hormonal fluctuations during menstruation, increasing breast pain and sensitivity.
Client gave birth 4 hr ago and is experiencing excessive vaginal bleeding.
A nurse is caring for a client who gave birth 4 hr ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle.
- B. Insert an indwelling urinary catheter.
- C. Massage the client's fundus.
- D. Initiate an infusion of oxytocin.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, which is the first-line intervention to control postpartum hemorrhage caused by uterine atony.
Newborn with hyperbilirubinemia and a prescription for phototherapy.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hours.
- B. Apply moisturizing lotion to the newborn's skin every 4 hours.
- C. Reposition the newborn every 2 to 3 hours.
- D. Give the newborn 1 oz of glucose water every 4 hours.
Correct Answer: C
Rationale: Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.
For each body system below, specify the potential manifestations that the client may experience. Match each body system with the potential manifestation.
- A. Nausea
- B. Pain
- C. Headache
- D. Body aches
Correct Answer: D
Rationale: General: Body aches (D) - reflects systemic discomfort. Head, ears, eyes, nose, and throat: Headache (C) - common neurological symptom. Gastrointestinal: Nausea (A) - due to digestive disturbances. Breast: Pain (B) - related to tissue sensitivity or engorgement.