Nokea
The nurse is teaching a prenatal class about kick counts. When should the client contact the healthcare provider?
- A. Fewer than 10 movements in 2 hours.
- B. Fewer than 5 movements in 1 hour.
- C. No movements after a meal.
- D. No movements for 6 hours.
Correct Answer: A
Rationale: Fewer than 10 movements in 2 hours is concerning and warrants further evaluation.
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What is the priority for a newborn presenting with grunting and nasal flaring?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Start IV fluids to maintain hydration
- C. Position the newborn in a semi-Fowler's position
- D. Administer antibiotics to prevent infection
Correct Answer: A
Rationale: Administering oxygen helps improve oxygenation for a newborn in respiratory distress.
The nurse is performing Leopold's maneuvers on a pregnant client. What is the primary purpose?
- A. Assess fetal heart tones.
- B. Determine fetal position.
- C. Evaluate amniotic fluid volume.
- D. Check for uterine contractions.
Correct Answer: B
Rationale: Leopold's maneuvers help determine the position and presentation of the fetus within the uterus.
The nurse is caring for a client with severe preeclampsia. What is the priority nursing action?
- A. Administer antihypertensive medication.
- B. Assess for signs of impending eclampsia.
- C. Monitor urine protein levels.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Assessing for signs of impending eclampsia, such as severe headache or visual changes, is critical to prevent seizures.
A delivering patient presses the call light and reports that her water just broke the nurse first action should be:
- A. Check the fetal heart tone
- B. Call physician
- C. Change bed linen
- D. Encourage mother to go for a walk
Correct Answer: A
Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.