Nokea
The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
- A. Calcium.
- B. Iron
- C. Folic acid.
- D. Vitamin D.
Correct Answer: C
Rationale: Folic acid is essential for preventing neural tube defects, including anencephaly, and is recommended for women of childbearing age.
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The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?
- A. Request a return demonstration of a diaper change
- B. Evaluate infant feeding techniques prior to discharge
- C. Provide the results of the infant's hearing test to the parents.
- D. Ensure that they have the pediatric clinic's phone number
Correct Answer: B
Rationale: Proper feeding techniques are critical for the infant's nutrition and growth, making evaluation of these skills the priority before discharge.
The nurse is assessing a newborn who was precipitously delivered at 38-weeks gestation The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to implement?
- A. Obtain a drug screen for cocaine
- B. Weigh and measure the newborn
- C. Determine reactivity of neonatal reflexes
- D. Perform gestational age assessment
Correct Answer: A
Rationale: Tremulousness, tachycardia, and hypertension in a newborn suggest possible drug exposure, such as cocaine, requiring an urgent drug screen to guide treatment.
The healthcare provider prescribes magnesium sulfate 6 grams intravenously (IV) to be infused over 20 minutes for client with preterm labor. The IV bag contains magnesium sulfate 20 grams in dextrose 5% in water 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)
Correct Answer: 450
Rationale: To deliver 6 grams over 20 minutes from a solution of 20 grams in 500 mL, the concentration is 25 mL/g. Thus, 6 grams requires 150 mL over 20 min, which is (150 mL / 20 min) x 60 = 450 mL/hour.
During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?
- A. Use a fingertip to palpate the inguinal canal for a weakening or indentation
- B. Measure the size of the scrotal sac for length and width.
- C. Perform transillumination of the scrotal sac to visualize shadows of the testes
- D. Observe the urethral opening on the surface of the penis when the newborn voids
Correct Answer: A
Rationale: Palpating the inguinal canal is the next step to check for undescended testes, which may be located in the inguinal area.
The healthcare provider prescribes oxytocin 2 milliunits/minute to induce labor for a client at 41-weeks gestation. The nurse initiates an infusion of Ringer's Lactate solution 1000 mL with oxytocin 10 units. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number)
Correct Answer: 12
Rationale: To deliver 2 milliunits/minute from a solution of 10 units (10,000 milliunits) in 1000 mL, the concentration is 10 milliunits/mL. Thus, 2 milliunits/minute requires 0.2 mL/minute, which is 0.2 x 60 = 12 mL/hour.