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A nurse is caring for a 2-day-old newborn who is undergoing phototherapy for treatment of hyperbilirubinemia.
Which of the following actions should the nurse take?
- A. Provide additional hydration by offering glucose water.
- B. Apply a water-based lotion to the newborn's skin every 4 hr.
- C. Monitor the newborn's heart rate every 2 hr.
- D. Remove the newborn from phototherapy every 2 hr for breastfeeding
Correct Answer: D
Rationale: Frequent breastfeeding enhances bilirubin excretion through stooling and supports hydration during phototherapy.
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Nurses' Notes: Client at 28 weeks, gravida 4, para 3, vaginal bleeding for 2 hr, saturating pads with bright red blood, no abdominal pain. Abdomen soft, nontender, fundal height 27 cm, FHR 170/min with minimal variability. Vital Signs: Temp 36.6°C, HR 120/min, RR 22/min, BP 86/48 mm Hg, O2 sat 96%. Diagnostic Results: Hct 25%, Hgb 9 g/dL, Platelet 110,000/mm3, WBC 12,000/mm3, Blood type B+.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Condition: ___ Actions: ___ Parameters: ___
- A. Monitor administration of ampicillin 2g IV bolus, Reinforce with the client to maintain bed rest, Administer methotrexate, Insert a large bore peripheral IV cathete, Assist the client with positioning for a vaginal examination
- B. Ectopic pregnancy, Placenta Previa, Cervical insufficiency, Chorioamnionitis
- C. Cervical dilatation, Vaginal bleeding, Fetal wellbeing, WBC count, Beta human chorionic gonadotropin levels
Correct Answer: A
Rationale: Painless, bright red bleeding at 28 weeks suggests placenta previa. Bed rest minimizes bleeding risk, and IV access prepares for fluid resuscitation. Monitoring bleeding and fetal well-being assesses stability.
A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 50 degree angle.
- B. I will place the retainer clip at the level of my baby's armpits.
- C. I will place a thick, soft pad behind my baby's back.
- D. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
Correct Answer: B
Rationale: The chest clip should be at armpit level to ensure proper harness positioning for maximum safety.
A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?
- A. Position the lap belt across your navel.
- B. Wear the shoulder harness snug across your stomach.
- C. Take a break and walk at least once every hour during long trips.
- D. Move your car seat forward, close to the steering wheel.
Correct Answer: C
Rationale: Walking every hour during long trips improves circulation and reduces the risk of deep vein thrombosis.
A nurse is reinforcing teaching about preterm labor with a client who is at 28 weeks of gestation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect to feel pain in my upper right abdomen if I'm having preterm labor.
- B. If I have contractions more often than every 10 minutes, I might be in preterm labor.
- C. I might be experiencing preterm labor if walking stops my contractions.
- D. I can take a daily iron supplement to prevent preterm labor.
Correct Answer: B
Rationale: Frequent contractions (more than every 10 minutes) indicate possible preterm labor, requiring medical evaluation.
A nurse in an antepartum unit is assisting with the care of a client who has preeclampsia and is receiving IV magnesium sulfate therapy.
For which of the following adverse effects should the nurse monitor and report to the provider?
- A. Polyuria
- B. Hyporeflexia
- C. Agitation
- D. Tachypnea
Correct Answer: B
Rationale: Hyporeflexia is an early sign of magnesium toxicity, indicating excessive neuromuscular blockade, requiring immediate reporting.