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What is the nurse's first action for a newborn showing signs of hypoglycemia?
- A. Feed the newborn formula immediately
- B. Encourage breastfeeding or formula feeding
- C. Monitor glucose levels every hour
- D. Notify the healthcare provider immediately
Correct Answer: A
Rationale: The correct answer is A: Feed the newborn formula immediately. The first action for a newborn showing signs of hypoglycemia is to provide them with a source of glucose to raise their blood sugar levels quickly. Formula feeding is an effective way to achieve this as it provides a concentrated source of glucose. Encouraging breastfeeding or formula feeding (choice B) is a good option but may not address the immediate need for glucose. Monitoring glucose levels every hour (choice C) is important but not the first action to take in an acute situation. Notifying the healthcare provider immediately (choice D) is necessary but should come after addressing the immediate need for glucose.
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A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. Prolonged contractions can indicate uterine hyperstimulation, leading to decreased fetal oxygenation. Staff should report this to the provider for further evaluation and management.
Explanation:
1. Contraction durations of 95 to 100 seconds are prolonged and may indicate uterine hyperstimulation, potentially compromising fetal oxygenation.
2. Reporting this finding to the provider allows for timely intervention to prevent fetal distress.
3. Choices B, C, and D do not directly indicate a concern for fetal well-being during labor and would not require immediate reporting to the provider.
The nurse is performing a nonstress test. What result indicates a reactive test?
- A. No fetal movements noted.
- B. Two accelerations in 20 minutes.
- C. Baseline fetal heart rate of 170 beats/minute.
- D. Variable decelerations.
Correct Answer: B
Rationale: The correct answer is B because two accelerations in 20 minutes are indicative of a reactive nonstress test. This pattern suggests that the fetal heart rate is reacting appropriately to fetal movement, indicating good oxygenation and neurologic integrity. Choice A is incorrect as fetal movements are essential for the test. Choice C is incorrect as a baseline heart rate of 170 bpm is considered high. Choice D is incorrect as variable decelerations are concerning for fetal distress.
What question during a family assessment could the nurse ask to determine if the family has necessary resources?
- A. Do you enjoy spending time with your family?
- B. Do you have a group of friends, neighbors, or a church that helps you when you are ill?
- C. How often do you go to the store by yourself?
- D. Do your family members get along well?
Correct Answer: B
Rationale: The correct answer is B: "Do you have a group of friends, neighbors, or a church that helps you when you are ill?" This question assesses the family's support network and resources in times of need. It helps determine if the family has a social support system that can provide assistance during challenging situations. Options A, C, and D are incorrect as they do not directly address the availability of external resources for the family's well-being. Option A focuses on emotional aspects, C on independence, and D on family dynamics, which are not directly related to assessing resources.
A 45-year-old woman presents to the clinic for advice about contraception. What is the most appropriate contraception method for a woman who is nearing menopause?
- A. Oral contraceptives with estrogen
- B. Contraceptive injections
- C. IUD with progestin
- D. Barrier methods like condoms
Correct Answer: C
Rationale: The most appropriate contraception method for a woman nearing menopause is an IUD with progestin (Choice C). Progestin-containing IUDs are effective, long-lasting, and suitable for women of various ages. As women approach menopause, the hormonal changes make progestin-containing IUD a favorable option as it offers reliable contraception without the need for daily administration. Additionally, progestin can also help alleviate symptoms like heavy periods that women may experience during perimenopause.
Choices A and B are not ideal as oral contraceptives with estrogen can increase the risk of blood clots in older women, and contraceptive injections may not be as convenient for someone nearing menopause. Barrier methods like condoms (Choice D) are less effective and may not provide the level of protection needed during this stage of life.
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.