Nokea
A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization?
- A. An Rh-negative mother who has an Rh- positive infant
- B. An Rh –positive mother who has an Rh- negative infant
- C. An Rh-positive mother who has an Rh- positive infant
- D. An Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: An Rh-negative mother who has an Rh-positive infant. This mother is at risk for developing Rh isoimmunization, a condition where her immune system attacks the Rh-positive red blood cells of her infant, potentially causing harm in future pregnancies. Rh(D) Immune globulin is given to prevent this by blocking the mother's immune response to the Rh-positive cells of the infant. The other choices do not require Rh(D) Immune globulin because they do not involve the risk of Rh isoimmunization. Choice B involves an Rh-positive mother who is not at risk of isoimmunization. Choice C involves an Rh-positive mother with an Rh-positive infant, so there is no incompatibility. Choice D involves an Rh-negative mother with an Rh-negative infant, so there is no risk of isoimmunization.
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A nurse is providing discharge instructions to a client who is breastfeeding her newborn.
- A. Expect 2 to 4 wet diapers every 24 hours
- B. Allow the baby to feed at least every 3 hours
- C. Offer the newborn 30 mL (1 oz.) of water between feedings
- D. Feed the newborn 5 to 10 minutes per breast
Correct Answer: B
Rationale: The correct answer is B: Allow the baby to feed at least every 3 hours. This is important for maintaining the baby's hydration, ensuring proper nutrition, and promoting successful breastfeeding. Feeding on demand helps establish a good milk supply and supports the baby's growth and development. Offering water (choice C) is unnecessary and can interfere with breastfeeding. Limiting feeding time to 5-10 minutes per breast (choice D) can prevent the baby from getting enough hindmilk, which is rich in fat and important for weight gain. Expecting 2-4 wet diapers every 24 hours (choice A) is a general guideline but not as crucial as ensuring frequent feedings for a breastfeeding newborn.
A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. This is an abnormal finding as typical contraction durations should be around 60-90 seconds. Prolonged contractions can lead to decreased fetal oxygenation and distress. Choice B is incorrect as contractions 2-3 minutes apart are within the normal range. Choice C is incorrect as absent early deceleration is a reassuring sign of fetal well-being. Choice D is incorrect as a fetal heart rate of 140/min is within the normal range of 110-160/min.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose level every hr. Neonatal abstinence syndrome can lead to hypoglycemia in infants. Monitoring blood glucose levels every hour allows for early detection and intervention. Providing a stimulating environment (A) can worsen symptoms. Initiating seizure precautions (C) is not necessary unless seizures are present. Placing the infant on his back with legs extended (D) does not address the specific issue of neonatal abstinence syndrome.
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
A nurse on the labor and delivery unit is assessing four clients. Which of the following clients is a candidate for an induction of labor with misoprostol?
- A. A client who has active genital herpes
- B. A client who has gestational diabetes mellitus
- C. A client who has a previous uterine incision
- D. A client who has placenta previa
Correct Answer: B
Rationale: The correct answer is B: A client who has gestational diabetes mellitus. Induction of labor with misoprostol is safe for clients with gestational diabetes mellitus as it does not affect blood glucose levels. Misoprostol is contraindicated in clients with active genital herpes (Choice A) due to risk of viral transmission. It is also contraindicated in clients with a previous uterine incision (Choice C) as it may increase the risk of uterine rupture. Clients with placenta previa (Choice D) should not undergo induction with misoprostol due to the risk of increasing bleeding.