Nokea
A nurse is caring for a client who is 6 weeks of gestation and reports nausea and vomiting. Which of the following Recommendations should the nurse make?
- A. Avoid Eating snacks before bedtime
- B. Eat high-fat snack before getting out of bed
- C. Drink additional liquids with each meal
- D. Consume food served at cool temperatures
Correct Answer: D
Rationale: The correct answer is D: Consume food served at cool temperatures. This recommendation is based on the fact that pregnant women experiencing nausea and vomiting (commonly known as morning sickness) may find relief by consuming cold or cool foods, as they are less likely to trigger nausea compared to hot or warm foods. Cold foods also tend to have less of a strong smell, which can help reduce nausea. Avoiding snacks before bedtime (choice A) may not necessarily alleviate nausea in the morning. Eating high-fat snacks before getting out of bed (choice B) may worsen nausea. Drinking additional liquids with each meal (choice C) may not address the underlying cause of nausea and could potentially make it worse.
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A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?
- A. Contractions last 60 Seconds
- B. Non-repetitive early decelerations
- C. 6 contractions in 10 minutes
- D. Moderate variability of the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: 6 contractions in 10 minutes. This indicates hyperstimulation of the uterus, putting the fetus at risk. Discontinuing oxytocin is necessary to prevent uterine tachysystole. Contractions lasting 60 seconds (choice A) are normal. Non-repetitive early decelerations (choice B) are benign. Moderate variability of the fetal heart rate (choice D) is a reassuring sign of fetal well-being.
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics
- B. Cleanse the site with Povidone iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial in preventing infection in a newborn with myelomeningocele where the spinal cord is exposed. Infection can lead to serious complications. Administering broad-spectrum antibiotics helps to reduce the risk of infection. Cleansing the site with Povidone iodine (choice B) is important, but antibiotics are necessary for prophylaxis. Monitoring rectal temperature (choice C) is not directly related to preventing infection. Surgical closure (choice D) after 72 hours is important, but antibiotics are essential immediately post-birth to prevent infection.
A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Administer 50 mL of dextrose solution IV
- B. Obtain a blood sample of serum glucose level
- C. Reassess the blood glucose level prior to the next feeding
- D. Feed the newborn immediately
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. In this scenario, the newborn's blood glucose level is 65 mg/dL, which is considered low. Given that the mother has Type 2 diabetes, the baby is at risk for hypoglycemia due to maternal hyperglycemia during pregnancy. Feeding the newborn immediately will help increase their blood glucose levels. IV dextrose solution administration (choice A) is not necessary at this time as the baby can be orally fed. Obtaining a blood sample for serum glucose level (choice B) can be done later after feeding to confirm improvement. Reassessing blood glucose prior to the next feeding (choice C) delays necessary intervention. The baby must be fed promptly to prevent further hypoglycemia.
A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1 hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1 hour glucose tolerance test. At 24-week prenatal appointment, screening for gestational diabetes is crucial. This test helps identify any glucose intolerance in pregnant women. The other choices are incorrect because: B: Rubella titer is typically done earlier in pregnancy to assess immunity. C: Group B strep culture is usually done around 35-37 weeks to determine if the mother needs antibiotics during labor. D: Blood type and Rh testing are important but are usually done earlier in pregnancy to determine if the mother is Rh negative and needs Rhogam.
A nurse is preparing to perform a fundal massage for a postpartum client with hearing seeing uterine atony. In which order should the nurse plan to perform the following actions? (molded steps into the box on the right. Placing them in order of performance use all steps)
- A. Ask the client to lie on her back in with her knees flexed
- B. Position one hand around the top of the client9s when fundus in one hand just above the client's symphysis pubis
- C. Rotate the upper hand to massage that clients uterus while using slight downward pressure to compress the fundus
- D. observe the client's perineum for the passage of clots and the amount of bleeding
Correct Answer: A,B,C,D
Rationale: Correct order of actions for fundal massage:
A: Ask the client to lie on her back with knees flexed - This position allows easy access to the uterus.
B: Position one hand around the top of the client's fundus and one hand just above the symphysis pubis - Proper positioning ensures effective massage.
C: Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus - This helps to stimulate contraction and control bleeding.
D: Observe the client's perineum for the passage of clots and the amount of bleeding - Monitoring for complications is essential.
Summary:
E: Not applicable - No action specified.
F: Not applicable - No action specified.
G: Not applicable - No action specified.
Incorrect choices:
The other choices are incorrect as they do not follow the logical sequence required for performing a fundal massage effectively and safely.