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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 hours.
- C. Remove the newborn from phototherapy every 2 hours for breastfeeding.
- D. Monitor the newborn's heart rate every 2 hours.
Correct Answer: C
Rationale: Removing the newborn for breastfeeding every 2 hours ensures nutrition and bonding without significantly disrupting phototherapy.
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A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Place the client in knee-chest position.
- B. Give a bolus of lactated Ringer's.
- C. Administer methylergonovine IM.
- D. Assist the client to empty her bladder.
Correct Answer: B
Rationale: Giving a bolus of lactated Ringer's solution can help increase the client's blood pressure by expanding the intravascular volume, a common intervention for hypotension caused by epidural anesthesia.
A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Take sips of milk between meals.
- B. Eat three large meals per day.
- C. Drink a cup of black coffee before breakfast.
- D. Lie in a left side-lying position for 30 minutes after meals.
Correct Answer: A
Rationale: Taking sips of milk neutralizes stomach acid, soothing heartburn, a safe and effective remedy during pregnancy.
A nurse is reinforcing teaching with a client about laboratory testing during pregnancy.
Which of the following statements should the nurse include in the teaching?
- A. A multiple marker screening will be performed to identify neural tube defects.
- B. A glucose tolerance test will be performed to predict hyperglycemia in your baby.
- C. A Papanicolaou test will be performed to detect the presence of herpes simplex type 1.
- D. A group B streptococcus screening will be performed to determine the presence of STIs.
Correct Answer: A
Rationale: A multiple marker screening detects neural tube defects and chromosomal abnormalities, typically performed between 15-20 weeks of gestation.
A nurse is reinforcing teaching about travel with a client who is pregnant.
Which of the following instructions should the nurse include?
- A. Take a break and walk at least once every hour.
- B. Wear the shoulder harness snug across your shoulder.
- C. Position the lap belt across your hips.
- D. Move your car seat forward, close to the steering wheel.
Correct Answer: A
Rationale: Taking breaks and walking hourly during travel improves circulation, reducing the risk of blood clots, a key concern during pregnancy.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever.
- B. Diarrhea.
- C. Sedation.
- D. Diuresis.
Correct Answer: C
Rationale: Sedation is a known adverse effect of nalbuphine hydrochloride as it acts on the central nervous system to relieve pain, which can cause drowsiness.