Nokea
For which condition should the nurse immediately
- A. Applying her peri-pad from back to front with notify the health care team?
- B. Periodic breathing in the newborn lasting
- C. Using the peri-bottle to rinse her perineum after approximately 3 to 5 seconds
- D. Blood sugar recording of 60 mg/dL in an infant born 6 hours ago
Correct Answer: D
Rationale: A blood sugar recording of 60 mg/dL in an infant born 6 hours ago requires immediate notification of the health care team. This low blood sugar level, also known as hypoglycemia, is a critical concern in newborns as it can lead to serious complications if not promptly addressed. Infants are particularly vulnerable to hypoglycemia due to their limited glycogen stores and high metabolic demands, which can result in inadequate glucose production. Immediate intervention and close monitoring by the healthcare team are essential to prevent potential long-term neurological consequences associated with hypoglycemia in newborns.
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A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A
Rationale: In placenta previa, the placenta partially or completely covers the cervix, which can lead to vaginal bleeding. Continuous monitoring of the fetal heart rate (FHR) is crucial in this situation to assess the well-being of the fetus. Any signs of distress or changes in the FHR can indicate potential complications, such as fetal hypoxia. This monitoring allows for prompt intervention if necessary to ensure the safety of both the mother and the baby. Administering betamethasone may be indicated to promote fetal lung maturity in cases of anticipated preterm birth, but it is not the priority in this scenario where monitoring the fetal well-being is crucial. Checking the cervix for dilation every 8 hours is not necessary and may increase the risk of further bleeding. Misoprostol, a medication used to induce labor, is contraindicated in cases of placenta previa because it can cause further
What advice should the nurse give if a woman forgets to take a low-dose combination birth control pill?
- A. Take it as soon as she remembers, even if that means taking two pills in one day.
- B. Skip that pill and refrain from intercourse for the remainder of the month.
- C. Wear a pad for the next week because she will experience vaginal bleeding.
- D. Take an at-home pregnancy test at the end of the month to check for a pregnancy.
Correct Answer: A
Rationale: Taking the missed pill promptly minimizes contraceptive failure.
Which sexually transmitted infection is characterized by multiple soft warts on the perineum and rectal areas?
- A. Human papillomavirus (HPV).
- B. Human immunodeficiency virus (HIV).
- C. Syphilis.
- D. Trichomoniasis.
Correct Answer: A
Rationale: HPV can cause genital warts, which appear as soft warts in the genital area.
A new mother asks the nurse why newborns receive an injection of vit. K after delivery. What will be the best response from the nurse?
- A. Newborns are given vit K to help with the digestion to help them absorb fat soluble vitamins
- B. Newborns are given vit K and erythromycin ointment to help prevent ophthalmia neonatorum
- C. Newborns lack the intestinal flora needed to produce vit K, so it is given to prevent bleeding episodes
- D. This vitamin substitutes for vitamin C and newborns will strengthen their immune system
Correct Answer: C
Rationale: Vitamin K is essential for clotting and prevents hemorrhagic disease.
The nurse is assessing a client with hyperemesis gravidarum. What finding requires immediate intervention?
- A. Urine output of 50 mL/hr.
- B. Weight loss of 5 pounds in 2 weeks.
- C. Dry mucous membranes and poor skin turgor.
- D. Nausea relieved by eating crackers.
Correct Answer: C
Rationale: Dehydration, indicated by dry mucous membranes and poor skin turgor, requires immediate intervention in hyperemesis gravidarum.