Nokea
What is the primary nursing action for a newborn experiencing signs of hypoglycemia?
- A. Administer glucose water via a bottle
- B. Feed the newborn breastmilk or formula
- C. Monitor glucose levels and reassess in 30 minutes
- D. Start an IV glucose drip
Correct Answer: B
Rationale: Feeding with breastmilk or formula is the most effective intervention for neonatal hypoglycemia.
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The nurse is caring for a client with gestational diabetes. What fetal complication should the nurse monitor for after birth?
- A. Hyperglycemia.
- B. Macrosomia.
- C. Hypoglycemia.
- D. Hyperbilirubinemia.
Correct Answer: C
Rationale: Newborns of mothers with gestational diabetes are at risk for hypoglycemia due to high insulin levels after birth.
What is one characteristic of the Alexander Technique the nurse can explain to a patient?
- A. taught only in person
- B. focused on unmedicated birth
- C. taught by a person who will assess the muscles and posture
- D. only useful for pregnancy but not birth
Correct Answer: C
Rationale: The Alexander Technique involves personalized assessment of posture and muscle tension by a trained instructor.
The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
A neonate is being discharged home with a fiber-optic blanket for treatment of physiologic jaundice. What is important for the nurse to include in the discharge instructions?
- A. Cover the infant's eyes during the treatment.
- B. Reduce the daily number of formula feedings.
- C. Encourage frequent feeding to increase intake.
- D. Expect a constipated stool until jaundice clears.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the discharge plan is to encourage frequent feeding to increase intake. Fiber-optic blankets for treating physiologic jaundice work by promoting the breakdown of bilirubin in the skin through phototherapy. Encouraging frequent feeding helps increase the infant's intake, leading to more frequent bowel movements which aids in the elimination of excess bilirubin from the body. This, in turn, helps in resolving physiologic jaundice more quickly. Covering the infant's eyes during treatment may be necessary to protect them from the bright light, but it is not directly related to the effectiveness of the treatment. Reducing the number of formula feedings could decrease the baby's intake, potentially leading to more concentrated levels of bilirubin. Expecting constipation until jaundice clears is not a typical consequence of using a fiber-optic blanket for jaundice treatment.
The nurse is educating a client about signs of labor. Which statement indicates understanding?
- A. False labor contractions cause cervical changes.
- B. True labor contractions decrease with activity.
- C. True labor contractions become stronger and more regular.
- D. False labor contractions are felt in the back.
Correct Answer: C
Rationale: True labor is characterized by regular, strong contractions that lead to cervical changes.