Nokea
What education does the nurse provide to a person taking Ella for emergency contraception?
- A. abstain from sex or use a barrier method for 5 days and then restart their COCs
- B. abstain from sex or use a barrier method until their menses occur and then restart their COCs
- C. restart their COCs the next day; no backup method is needed
- D. restart their COCs the next day and use a backup method for 7 days
Correct Answer: D
Rationale: The education the nurse should provide to a person taking Ella for emergency contraception is to restart their COCs the next day and use a backup method, such as condoms, for 7 days. This is important to ensure continued protection against pregnancy, as Ella may potentially reduce the effectiveness of the COCs. Using a backup method during this time is essential to prevent unintended pregnancy.
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The nurse teaches a new mother that neonatal weight loss in the first 3 days of life is most often the result of:
- A. Allergy to formula
- B. a hypoglycemic response
- C. Inadequate breast or formula feeding
- D. Excretion of fluid via lungs, urinary bladder and bowels.
Correct Answer: C
Rationale: Neonatal weight loss in the first 3 days of life is most often the result of inadequate breast or formula feeding. During the initial days of life, it is normal for newborn babies to experience some weight loss. This weight loss is generally due to factors such as insufficient intake of breast milk or formula. It takes a few days for a mother's mature breast milk to come in, and during this time, a newborn may not receive enough colostrum, which can lead to initial weight loss. Similarly, if a baby is not getting enough formula or is having feeding difficulties, this can also result in weight loss. Allergy to formula, a hypoglycemic response, or excretion of fluid via lungs, urinary bladder, and bowels are less likely explanations for neonatal weight loss in the first 3 days of life compared to inadequate feeding.
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.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs.
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: The correct action the nurse should include in the care plan for a newborn undergoing phototherapy using a lamp is to ensure that the newborn's eyes are closed beneath the shield. This is important to protect the newborn's eyes from exposure to the bright light emitted during phototherapy, as prolonged exposure can lead to eye damage. Keeping the eyes closed under the shield helps prevent potential harm and ensures the safety and well-being of the newborn during the treatment. Applying a thin layer of lotion, giving glucose water, or dressing the newborn in clothing are not relevant or appropriate actions for phototherapy care in this scenario.
The nurse is caring for a client at 39 weeks' gestation in active labor. The fetal monitor shows late decelerations. What is the priority nursing action?
- A. Reposition the client to her left side.
- B. Increase the oxytocin infusion rate.
- C. Encourage the client to push harder.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: Repositioning improves uteroplacental blood flow and oxygen delivery to the fetus, addressing late decelerations.
A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first
- A. Assess client's blood pressure.
- B. Assess the bladder for distention.
- C. Massage the client's fundus.
- D. Prepare to administer a prescribed oxytocic preparation.
Correct Answer: B
Rationale: The first action the nurse should take in this situation is to assess the bladder for distention. Postpartum hemorrhage can be caused by a distended bladder putting pressure on the uterus, preventing it from contracting effectively and leading to excessive bleeding. By assessing for bladder distention and ensuring the client empties her bladder, the nurse can help the uterus contract more efficiently and potentially reduce the bleeding. Assessing the other options such as blood pressure, massaging the fundus, and preparing to administer an oxytocic can be important interventions eventually, but addressing the bladder distention is the first priority in this case of excessive postpartum bleeding.