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The nurse on the postpartum mother-baby unit is assigned to take care of four couplets and a new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can delegate care for which couplet to the unlicensed nursing personnel?
- A. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin.
- B. A G4 P4 who is breast-feeding an 8 lb infant without difficulty.
- C. A G3 P3 postpartum client who is receiving Magnesium Sulfate and whose infant has a respiratory rate of 20.
- D. A G2 P2 who delivered vaginally 2 days ago with an infant having low blood glucose levels the first 24 hours post delivery.
Correct Answer: B
Rationale: The G4 P4 client with stable breastfeeding is appropriate for UAP delegation, as no complex medical needs are present.
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Initial assessment of a term female neonate about 4 hours old reveals a normal anterior fontanel. The nurse documents its shape as which of the following?
- A. Oval.
- B. Square.
- C. Diamond shaped.
- D. Triangular.
Correct Answer: C
Rationale: The anterior fontanel in a term neonate is typically diamond-shaped.
The nurse is instructing a preeclamptic client about monitoring the movements of her fetus to determine fetal well-being. Which statement by the client indicates that she needs further instruction about when to call the health care provider concerning fetal movement?
- A. "If the fetus is becoming less active than before."
- B. "If it takes longer each day for the fetus to move 10 times."
- C. "If the fetus stops moving for 12 hours."
- D. "If the fetus moves more often than 3 times an hour."
Correct Answer: D
Rationale: Increased fetal movement can be a sign of distress, so the client should be instructed to report any significant changes in movement.
A male neonate born at 36 weeks' gestation is admitted to the neonatal intensive care nursery with a diagnosis of probable fetal alcohol syndrome (FAS). The mother visits the nursery soon after the neonate is admitted. Which of the following instructions should the nurse expect to include when developing the teaching plan for the mother about FAS?
- A. Withdrawal symptoms usually do not occur until 7 days postpartum.
- B. Large-for-gestational-age size is common with this condition.
- C. Facial deformities associated with FAS can be corrected by plastic surgery.
- D. Symptoms of withdrawal include tremors, sleeplessness, and seizures.
Correct Answer: D
Rationale: Symptoms of withdrawal in FAS include tremors, sleeplessness, and seizures due to neurological effects of alcohol exposure.
The physician orders 1000 mL of Ringer's Lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute?
- A. 25 gtts/minute.
- B. 30 gtts/minute.
- C. 35 gtts/minute.
- D. 40 gtts/minute.
Correct Answer: A
Rationale: Calculation: (1000 mL * 12 gtts/mL) / (8 hours * 60 minutes) = 25 gtts/minute.
Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding?
- A. Breast milk quality and richness are decreased.
- B. The mother's motivation to breast-feed is diminished.
- C. Medications may be excreted in breast milk to the nursing neonate.
- D. Medications interfere with the mother's letdown reflex.
Correct Answer: C
Rationale: Medications can pass into breast milk, potentially affecting the neonate, making this the primary concern.