Nokea
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Monitor blood glucose level every hr.
- B. Place the infant on his back with legs extended.
- C. Initiate seizure precautions.
- D. Provide a stimulating environment.
Correct Answer: C
Rationale: The correct answer is C: Initiate seizure precautions. Neonatal abstinence syndrome can result in neurological symptoms, including seizures. Initiating seizure precautions involves ensuring a safe environment, padding the crib, and closely monitoring the infant for any signs of seizure activity. Monitoring blood glucose every hour (A) is not typically indicated for neonatal abstinence syndrome. Placing the infant on his back with legs extended (B) is a standard safe sleep practice but is not specific to managing neonatal abstinence syndrome. Providing a stimulating environment (D) can exacerbate symptoms of withdrawal and should be avoided.
You may also like to solve these questions
A nurse is providing prenatal teaching to a client who practices a vegan diet and is trying to increase intake of vitamin B12. Which of the following foods should the nurse recommend?
- A. Fortified soy milk
- B. Raw carrots
- C. Fresh citrus fruits
- D. Brown rice
Correct Answer: A
Rationale: The correct answer is A: Fortified soy milk. Soy milk is often fortified with vitamin B12, making it a suitable option for vegans. Vitamin B12 is primarily found in animal products, so vegans need to rely on fortified foods or supplements. Raw carrots (B), fresh citrus fruits (C), and brown rice (D) do not contain significant amounts of vitamin B12 and are not suitable sources for increasing intake. It is important for the nurse to recommend a specific food that is known to be fortified with vitamin B12 to meet the client's dietary needs.
A nurse is caring for a client who is at 37 weeks of gestation and is being tested for group B streptococcus ß-hemolytic (GBS). The client is multigravida and multipara with no history of GBS. She asks the nurse why the test was not conducted earlier in her pregnancy. Which of the following is an appropriate response by the nurse?
- A. You didn't report any symptoms of GBS during your pregnancy.'
- B. Your previous deliveries were all negative for GBS.'
- C. There was no indication of GBS in your earlier prenatal testing.'
- D. We need to know if you are positive for GBS at the time of delivery.'
Correct Answer: D
Rationale: The correct answer is D: We need to know if you are positive for GBS at the time of delivery. This is the most appropriate response because GBS status can change throughout pregnancy, and the risk of transmitting GBS to the newborn is highest during delivery. Testing closer to the due date ensures the most accurate results.
A: Incorrect. GBS may not present with symptoms, so relying on symptoms alone is not a reliable method for testing.
B: Incorrect. Previous negative results do not guarantee current status, as GBS status can change.
C: Incorrect. Lack of indication in earlier prenatal testing does not rule out GBS at the time of delivery.
E, F, G: Not provided, but unnecessary as the correct answer has been identified.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: Rationale: The correct answer is D. In the occipitoposterior position, the fetus's head is pressing against the mother's sacrum, causing intense back pain known as back labor. By asking if the back labor has improved, the nurse can assess if the hands-and-knees position has helped relieve the pressure on the mother's sacrum, indicating effectiveness.
Incorrect Choices:
A: Suprapubic pain is not directly related to the occipitoposterior position or the hands-and-knees position.
B: Pelvic pressure may not necessarily be alleviated by changing positions in occipitoposterior position.
C: Contractions feeling further apart may not directly correlate with the effectiveness of the hands-and-knees position for back labor relief.
A nurse is preparing to administer metronidazole 2 g PO to a client who has trichomoniasis. Available is metronidazole 250 mg tablets. How many tablets should the nurse administer?
- A. 8 tablets
- B. 4 Tablets
- C. 2 tablets
- D. 1 tablet
Correct Answer: A
Rationale: The correct answer is A: 8 tablets. To calculate the number of tablets needed, divide the total dose (2 g) by the strength of each tablet (250 mg). 2 g is equal to 2000 mg. 2000 mg ÷ 250 mg = 8 tablets. Therefore, the nurse should administer 8 tablets of metronidazole. Choice B (4 tablets) is incorrect because it does not provide the correct dose of 2 g. Choice C (2 tablets) is incorrect as well, as it only provides half of the required dose. Choice D (1 tablet) is incorrect because it does not meet the prescribed dosage of 2 g.
A nurse is caring for a client who is receiving oxytocin via continuous IV infusion and is experiencing persistent late decelerations in the FHR. After discontinuing the infusion, which of the following actions should the nurse take?
- A. Instruct the client to bear down and push with contractions.
- B. Administer oxygen at 10 L/min via nonrebreather facemask.
- C. Place the client in a supine position.
- D. Initiate an amnioinfusion.
Correct Answer: B
Rationale: The correct answer is B: Administer oxygen at 10 L/min via nonrebreather facemask. This action is appropriate because late decelerations in fetal heart rate (FHR) can indicate uteroplacental insufficiency, leading to fetal hypoxia. Administering oxygen helps increase the oxygen supply to the fetus, potentially improving fetal oxygenation and reducing the risk of hypoxia-related complications.
Choice A is incorrect because bearing down and pushing with contractions can further compromise fetal oxygenation in the presence of late decelerations. Choice C is incorrect as a supine position can worsen uteroplacental perfusion. Choice D, initiating an amnioinfusion, is not indicated for addressing late decelerations in FHR.