Nokea
The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
- A. Hypoglycemia.
- B. Hyperbilirubinemia.
- C. Hemorrhage.
- D. Polycythemia.
Correct Answer: C
Rationale: Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease due to low vitamin K levels, which are necessary for blood clotting.
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A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
A neonate born by cesarean delivery at 42 weeks' gestation, weighing 4.1 kg (9 lb, 1 oz), with Apgar scores of 8 at 1 minute and 9 at 5 minutes after birth, develops an increased respiratory rate and tremors of the hands and feet 2 hours postpartum. Which of the following nursing diagnoses would be the priority?
- A. Ineffective airway clearance related to postterm gestational age.
- B. Hyperthermia related to large size and use of a radiant warmer.
- C. Decreased cardiac output related to difficult delivery.
- D. Imbalanced nutrition: Less than body requirements related to depleted glycogen stores.
Correct Answer: D
Rationale: Tremors and increased respiratory rate suggest hypoglycemia due to depleted glycogen stores, a common issue in post-term neonates.
A breast-feeding primiparous client who delivered 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which of the following guidelines should the nurse include in the teaching plan as evidence of adequate intake?
- A. Six to eight wet diapers by the fifth day.
- B. Three to four transitional stools on the fourth day.
- C. Ability to fall asleep easily after feeding on the first day.
- D. Regain of lost birth weight by the third day.
Correct Answer: A
Rationale: Six to eight wet diapers by the fifth day indicate adequate milk intake.
The physician orders whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first:
- A. Validate client information and the blood product with another nurse.
- B. Check the vital signs before transfusing over 5 to 6 hours.
- C. Ask the client if she has ever had any allergies.
- D. Administer 100 mL of 5% dextrose solution intravenously.
Correct Answer: A
Rationale: Validating client information and blood product is essential to prevent transfusion errors.
A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, which of the following can the nurse teach the mother to do?
- A. Bring in toys for distraction.
- B. Place a musical mobile over the crib.
- C. Stroke the neonate's back.
- D. Use constant, gentle touch.
Correct Answer: D
Rationale: Constant, gentle touch is soothing and minimizes overstimulation for a sick neonate.