Nokea
The nurse has received shift report on a group of newborns. The nurse should make rounds on which of the following clients first?
- A. A newborn who is large for gestational age (LGA) who needs a repeat blood glucose prior to the next feeding in 15 minutes.
- B. A newborn delivered at 36-weeks' gestation weighing $5 \mathrm{lb}$ who is due to breast-feed for the first time in 15 minutes.
- C. A newborn who was delivered 24 hours ago by Cesarean section and had a respiratory rate of 62 30 minutes ago.
- D. A newborn who had a borderline low temperature and was double-wrapped with a hat on ½ hour ago to bring up the temperature.
Correct Answer: C
Rationale: A respiratory rate of 62 is elevated and may indicate respiratory distress, requiring immediate assessment.
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As a nurse begins her shift on the obstetrical unit, there are several new admissions. The client with which of the following conditions would be a candidate for induction?
- A. Pregnancy-induced hypertension (PIH).
- B. Active herpes.
- C. Face presentation.
- D. Fetus with late decelerations.
Correct Answer: A
Rationale: Pregnancy-induced hypertension (PIH) is an indication for induction to prevent maternal-fetal complications. Active herpes, face presentation, or late decelerations are contraindications due to risks of infection, dystocia, or fetal distress.
A primigravida admitted to the hospital with a diagnosis of hyperemesis gravidarum is placed on nothing-by-mouth(NPO) status and is receiving intravenous(IV) fluid replacement therapy. In planning this client's care, the nurse should collaborate with the health care provider(HCP) to carry out which of the following?
- A. Withhold oral fluids indefinitely until acidosis is corrected.
- B. Give oral fluids in small quantities whenever the client desires.
- C. Per HCP orders, provide clear liquids by mouth after 24 hours if vomiting subsides.
- D. Withhold oral fluids until total parenteral nutrition replaces lost electrolytes.
Correct Answer: C
Rationale: Gradual reintroduction of oral fluids is appropriate once vomiting subsides.
A couple is inquiring about vasectomy as a permanent method of contraception. Which teaching statement would the nurse include in the teaching plan?
- A. Another method of contraception is needed until the sperm count is 0.
- B. Vasectomy is easily reversed if children are desired in the future.
- C. Vasectomy is contraindicated in males with prior history of cardiac disease.
- D. Vasectomy requires only a yearly follow-up once the procedure is completed.
Correct Answer: A
Rationale: After a vasectomy, another contraception method is needed until a follow-up semen analysis confirms a zero sperm count, ensuring sterility.
The physician orders ampicillin The dose is 100 mg/kg per dose for a newly admitted neonate. The neonate weighs 1,350 grams. How many milligrams should the nurse administer?
- A. mg.
Correct Answer: B
Rationale: The neonate weighs 1,350 g (1.35 kg). The dose is 100 mg/kg, so 100 mg/kg × 1.35 kg = 135 mg. The nurse should administer 135 mg.
The physician determines that outlet forceps are needed to assist in the delivery of a primigravid client in active labor with a large-for-gestational-size fetus. The nurse reinforces the physician's explanation for using forceps based on the understanding about which of the following concerning the location of the fetus?
- A. Fetal head at the pelvic outlet.
- B. Fetal head at the ischial spines.
- C. Fetal head above the pelvic brim.
- D. Fetal head in the false pelvis.
Correct Answer: A
Rationale: Outlet forceps are used when the fetal head is at the pelvic outlet, visible at the perineum, allowing safe assisted delivery. Higher fetal positions require different interventions.