Nokea
The nurse is to draw a blood sample for glucose testing from a term neonate during the first hour after birth. The nurse should obtain the blood sample from the neonate's foot near which of the following areas?
Correct Answer: B
Rationale: The blood sample should be obtained from the lateral or medial heel of the neonate's foot to minimize pain and avoid major nerves and blood vessels.
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A primiparous client who will be bottle-feeding her neonate asks, "What is the best position for the baby after feeding?" Which of the following positions should the nurse recommend to aid digestion?
- A. Supine position.
- B. On the left side.
- C. Prone with the infant's head elevated on a pillow.
- D. Sitting on the caregiver's lap for 20 minutes.
Correct Answer: D
Rationale: Sitting upright after feeding aids digestion by allowing gravity to keep formula in the stomach.
A preterm neonate who has been stabilized is placed in a radiant warmer and is receiving oxygen via an oxygen hood. While administering oxygen in this manner, the nurse should do which of the following?
- A. Humidify the air being delivered.
- B. Cover the neonate's scalp with a warm cap.
- C. Record the neonate's temperature every 3 to 4 minutes.
- D. Assess the neonate's blood glucose level.
Correct Answer: A
Rationale: Humidifying the air prevents drying of the mucous membranes and maintains airway moisture, which is critical for preterm neonates.
When developing the plan of care for a multigravid client with class III heart disease, which of the following areas should the nurse expect to assess frequently?
- A. Dehydration.
- B. Nausea and vomiting.
- C. Iron-deficiency anemia.
- D. Tachycardia.
Correct Answer: D
Rationale: Class III heart disease indicates significant cardiac limitation, making tachycardia a critical sign of cardiac stress during labor. Frequent assessment ensures early detection of decompensation. Dehydration, nausea, or anemia are less immediate concerns.
A primigravid client at 36 weeks' gestation with premature rupture of the membranes is to be discharged home on bed rest with follow-up by the home health nurse. After instruction about care while at home, which of the following client statements indicates effective teaching?
- A. "It is permissible to douche if the fluid irritates my vaginal area."
- B. "I can take either a tub bath or a shower when I feel like it."
- C. "I should limit my fluid intake to less than 1 quart daily."
- D. "I should contact the doctor if my temperature is 100.4° F or higher."
Correct Answer: D
Rationale: Contacting the doctor for fever is appropriate.
Which of the following characteristics should the nurse teach the mother about her neonate diagnosed with fetal alcohol syndrome (FAS)?
- A. Neonates are commonly listless and lethargic.
- B. The IQ scores are usually average.
- C. Hyperactivity and speech disorders are common.
- D. The mortality rate is 70% unless treated.
Correct Answer: C
Rationale: Hyperactivity and speech disorders are common in FAS due to neurological and developmental impacts.