Nokea
The nurse is monitoring a client with premature rupture of membranes at 37 weeks. Which prescription should the nurse question?
- A. Monitor fetal heart rate continuously.
- B. Monitor maternal vital signs frequently.
- C. Perform a vaginal examination every shift.
- D. Administer an antibiotic as prescribed.
Correct Answer: C
Rationale: Vaginal exams are minimized to reduce the risk of infection in clients with premature rupture of membranes.
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A client at 28 weeks' gestation reports feeling fewer fetal movements. What should the nurse recommend first?
- A. Perform a nonstress test.
- B. Drink a glass of juice and lie down.
- C. Notify the healthcare provider immediately.
- D. Schedule an ultrasound.
Correct Answer: B
Rationale: Drinking juice and lying down can stimulate fetal movement and help evaluate whether further action is needed.
Which of the following is an abnormal finding upon
- A. To monitor hydration status physical examination of an infant?
- B. To reduce the risk of bladder injury
- C. Anterior fontanel that has a diamond-shaped open
- D. To prevent the patient from urinating during space surgery
Correct Answer: D
Rationale: The abnormal finding listed in option D, "To prevent the patient from urinating during space surgery," stands out from the rest of the options provided. This is because during space surgery, it is not necessary or appropriate to prevent the patient from urinating; rather, it is essential to focus on the surgical procedure and the patient's safety in a space environment. The other options focus on normal or abnormal physical examination findings in infants, such as the hydration status, fontanel appearance, suture line spacing, ear positioning, and uterus displacement.
What is the most appropriate action for a nurse when a newborn has jaundice on the second day of life?
- A. Increase fluid intake of the mother
- B. Phototherapy
- C. Monitor bilirubin levels
- D. Refer to a pediatric specialist
Correct Answer: B
Rationale: Phototherapy helps treat jaundice by breaking down bilirubin.
The nurse is caring for a pregnant client with a diagnosis of gestational diabetes. What finding indicates the need for immediate intervention?
- A. Blood sugar of 130 mg/dL after a meal.
- B. Fasting blood sugar of 95 mg/dL.
- C. Presence of ketones in the urine.
- D. Client reports increased thirst.
Correct Answer: C
Rationale: Ketones in the urine indicate poor glucose control and possible ketoacidosis, requiring urgent medical attention.
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: C
Rationale: Neonatal abstinence syndrome (NAS) occurs in infants who are exposed to addictive substances in utero, typically opioids. The signs of NAS can include irritability, tremors, feeding difficulties, and seizures. Therefore, it is essential for the nurse to initiate seizure precautions when caring for an infant with signs of NAS. This includes ensuring a safe environment, padding the crib, monitoring closely for seizure activity, and having emergency medications readily available if needed. Providing a stimulative environment (Option A) would be inappropriate as it can exacerbate symptoms of NAS. While monitoring blood glucose (Option B) is important in some situations, such as for infants of diabetic mothers, it is not the priority in NAS. Placing the infant on their back with legs extended (Option D) does not directly address the immediate concerns related to NAS.