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The nurse is monitoring a client with a history of stillborn infants. The nurse is aware that a nonstress test can be ordered for this client to:
- A. Determine lung maturity
- B. Measure the fetal activity
- C. Show the effect of contractions on fetal heart rate
- D. Measure the well-being of the fetus
Correct Answer: D
Rationale: A nonstress test assesses fetal well-being by monitoring fetal heart rate in response to movement, particularly in high-risk pregnancies.
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A client who experienced a cardiac arrest and resuscitation is exhibiting characteristics of mild anoxic brain injury. Which of the following characteristics does the nurse expect her to exhibit? Select all that apply.
- A. Decreased ability to concentrate.
- B. Seizures.
- C. Memory impairment.
- D. Semicomatose state.
- E. Decreased balance.
- F. Restlessness.
Correct Answer: A,C,E,F
Rationale: Mild anoxic brain injury may cause decreased concentration (A), memory impairment (C), decreased balance (E), and restlessness (F). Seizures (B) and semicomatose state (D) are more typical of severe injury.
The nurse is caring for a first-time mother who is asking how to help her baby sleep through the night as the baby gets older. Which recommendation should the nurse tell the mother?
- A. Rock her to sleep every night until she is in a deep sleep.
- B. Give diphenhydramine 12.5 mg orally to put the baby to sleep.
- C. If she starts waking up a lot in the middle of the night, put her in the bed with you.
- D. Give the last feeding as late as possible, and put her in the bed awake without a bottle.
Correct Answer: D
Rationale: Placing the baby in bed awake after a late feeding promotes self-soothing and healthy sleep habits, unlike the other options, which may create dependencies or safety risks.
The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is:
- A. Optimal restoration of the client's elimination pattern
- B. Restoration of the client's neurosensory function
- C. Prevention of complications from impaired elimination
- D. Promotion of a positive body image
Correct Answer: C
Rationale: The primary goal is to prevent complications like infections or skin breakdown by establishing effective bowel and bladder management.
The physician has ordered a serum aminophylline level for a client with chronic obstructive lung disease. The nurse knows that the therapeutic range for aminophylline is:
- A. 1-3 micrograms/mL
- B. 4-6 micrograms/mL
- C. 7-9 micrograms/mL
- D. 10-20 micrograms/mL
Correct Answer: D
Rationale: The therapeutic range for aminophylline is 10-20 micrograms/mL to effectively manage symptoms of chronic obstructive lung disease.
A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months, so a 7-pound newborn would weigh approximately 14 pounds.