Nokea
While evaluating the reflexes of the newborn, the nurse notes that with a loud noise the newborn symmetrically abduct and extend his arms, his fingers fan out and forms a c with the thumb and forefinger. What does the nurse document?
- A. Positive Moro reflex
- B. Positive Babinski reflex
- C. Rooting reflex
- D. Tonic neck reflex
Correct Answer: A
Rationale: The correct answer is A: Positive Moro reflex. The Moro reflex is elicited by a sudden loud noise or a jarring movement. The newborn symmetrically abducts and extends their arms, followed by fanning out their fingers and forming a "C" shape with the thumb and forefinger. This reflex is an involuntary response that indicates the normal development of the newborn's nervous system. The other choices are incorrect because:
B: Positive Babinski reflex is elicited by stroking the sole of the foot, resulting in the toes fanning out and big toe dorsiflexing.
C: Rooting reflex is elicited by touching the newborn's cheek, causing them to turn their head towards the stimulus and open their mouth to seek food.
D: Tonic neck reflex is elicited by turning the newborn's head to one side, causing extension of the arm on that side and flexion of the opposite arm.
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A postpartum client is getting ready to receive a Depo-Provera injection. Which statement by the client indicates that further teaching by the nurse is necessary?
- A. You will give this shot just like the rubella injection I received yesterday.
- B. I will watch my weight and try to exercise daily after receiving this injection.
- C. I will need to reschedule a follow-up appointment in 3 months.
- D. It might take me a year to get pregnant after receiving this type of birth control.
Correct Answer: A
Rationale: The correct answer is A because the client's comparison of receiving a Depo-Provera injection to a rubella injection is incorrect. Depo-Provera is a hormonal contraceptive injection that does not have the same administration process or purpose as a rubella vaccination. This indicates a lack of understanding about the medication.
Choice B is not the correct answer because it shows the client's awareness of the importance of weight management and exercise in conjunction with receiving the injection.
Choice C is not the correct answer because it demonstrates the client's understanding of the need for a follow-up appointment in 3 months which is necessary for monitoring and continuation of the contraceptive method.
Choice D is not the correct answer because it shows the client's understanding of the potential delay in fertility after discontinuing Depo-Provera, which is an important aspect of the contraceptive method that the client should be aware of.
The nurse is monitoring a client with severe preeclampsia. What finding requires immediate intervention?
- A. Proteinuria of +1.
- B. Respiratory rate of 16 breaths per minute.
- C. Deep tendon reflexes +4.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: The correct answer is C: Deep tendon reflexes +4. In severe preeclampsia, increased reflexes indicate possible progression to eclampsia with seizures. Immediate intervention is needed to prevent seizures. Choice A is not urgent unless higher proteinuria levels are present. Choice B is within normal range. Choice D is concerning but not as urgent as managing potential seizures.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn's temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. Phototherapy is used to treat jaundice by exposing the baby's skin to light. Lotions or ointments can interfere with the effectiveness of the light therapy. Dressing the newborn in lightweight clothing (choice A) is not directly related to the effectiveness of phototherapy. Keeping the newborn supine throughout treatment (choice C) is a general position recommendation and not specific to phototherapy. Measuring the newborn's temperature every 8 hours (choice D) is important but not directly related to phototherapy.
The nurse is preparing a client for a scheduled cesarean delivery. What is the priority preoperative instruction?
- A. Eat a high-protein meal before surgery.
- B. Empty your bladder before the procedure.
- C. Avoid brushing your teeth on the morning of surgery.
- D. Refrain from taking prescribed medications.
Correct Answer: B
Rationale: The correct answer is B: Empty your bladder before the procedure. This is the priority preoperative instruction because a full bladder can increase the risk of complications during surgery, such as injury to the bladder or difficulties in catheter insertion. It is essential to ensure the bladder is empty to provide a clear surgical field and prevent urinary retention postoperatively.
Explanation for other choices:
A: Eating a high-protein meal before surgery is not recommended as it can increase the risk of aspiration during anesthesia.
C: Avoiding brushing teeth on the morning of surgery is not a priority instruction. Maintaining oral hygiene is important, but it does not directly impact the surgical procedure.
D: Refraining from taking prescribed medications should be discussed with the healthcare provider, as certain medications may need to be taken even on the day of surgery to prevent complications.
The nurse is caring for a client in the third trimester reporting severe right upper quadrant pain and nausea. What condition should the nurse suspect?
- A. Placenta previa.
- B. HELLP syndrome.
- C. Hyperemesis gravidarum.
- D. Abruptio placentae.
Correct Answer: B
Rationale: The correct answer is B: HELLP syndrome. In the third trimester, severe right upper quadrant pain and nausea can indicate HELLP syndrome, a serious pregnancy complication involving hemolysis, elevated liver enzymes, and low platelet count. The pain and nausea are due to liver and gallbladder involvement. Placenta previa typically presents with painless vaginal bleeding, not upper quadrant pain. Hyperemesis gravidarum causes severe nausea and vomiting but not specific upper quadrant pain. Abruptio placentae presents with sudden-onset abdominal pain and vaginal bleeding.