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- A. Continue to observe the fetal monitor.
- B. Anticipate rupture of the membranes.
- C. Prepare for fetal oximetry.
- D. Discontinue the Pitocin infusion.
Correct Answer: D
Rationale: Oxytocin (Pitocin) stimulates uterine contractions. If it causes excessive uterine activity (e.g., more than 5 contractions in 10 minutes or contractions lasting longer than 90 seconds), it can reduce placental perfusion
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A neonate delivered at 37 weeks' gestation has been admitted to the neonatal intensive care unit for respiratory distress. The physician has ordered an I.V. for fluid support. To increase safety prior to hanging new I.V. fluids for a neonate, the nurse should:
- A. Check the neonate's weight.
- B. Determine if the neonate has adequate urine output.
- C. Determine the neonate's glucose level.
- D. Double-check the fluids and physician's order with another nurse.
Correct Answer: D
Rationale: Double-checking the fluids and physician's order with another nurse ensures accuracy and safety, reducing the risk of medication or fluid errors.
A nurse and a nursing assistant are caring for clients in a labor and delivery unit. Which task should the registered nurse assign to the nursing assistant?
- A. Perform a fundal check on a 2-day postpartum client.
- B. Remove a fetal monitor and assist a client to the bathroom.
- C. Give ibuprofen 800 mg by mouth to a newly delivered client.
- D. Teach a new mother how to bottle-feed her infant.
Correct Answer: B
Rationale: A nursing assistant can assist with mobility tasks like removing a fetal monitor and helping a client to the bathroom. Fundal checks, medication administration, and teaching require RN skills.
Which of the following would lead the nurse to suspect retinopathy of prematurity (ROP) when assessing a neonate at 32 weeks' gestation who weighs 2,000 g ?
- A. Sunken orbital sockets.
- B. Strabismus.
- C. Reaction to bright light.
- D. Constricted retinal vessels.
Correct Answer: D
Rationale: Constricted retinal vessels are a sign of ROP, indicating abnormal retinal vascular development.
A primiparous client, 48 hours after a vaginal delivery, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?
- A. Orange juice.
- B. Herbal tea.
- C. Milk.
- D. Grape juice.
Correct Answer: A
Rationale: Vitamin C in orange juice enhances iron absorption, unlike milk, which can inhibit it.
When developing the initial plan of care for a neonate who was born at 41 weeks' gestation, was diagnosed with meconium aspiration syndrome (MAS), and requires mechanical ventilation, which of the following should the nurse include:
- A. Care of an umbilical arterial line.
- B. Frequent ultrasound scans.
- C. Orogastric feedings as soon as possible.
- D. Assessment for symptoms of hyperglycemia.
Correct Answer: A
Rationale: Care of an umbilical arterial line is necessary for monitoring blood gases and blood pressure in a neonate on mechanical ventilation.