Nokea
A nurse is assisting with the care of a newborn who has neonatal abstinence syndrome.
Which of the following actions should the nurse take first?
- A. Swaddle the newborn in blankets
- B. Determine the newborn's respiratory rate
- C. Auscultate the newborn's bowel sounds.
- D. Weigh the newborn's wet diaper
Correct Answer: B
Rationale: Determining respiratory rate is the priority to assess for distress, as neonatal abstinence syndrome can cause tachypnea.
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Medical History: 26-year-old primigravida at 28 weeks, obese, no hypertension or diabetes history, presents with elevated blood pressure, peripheral edema, headaches. Physical Examination: Alert, oriented, 3+ deep tendon reflexes, +2 pitting edema, FHR 140/min with moderate variability. Diagnostic Results: Hgb 10 g/dL, Hct 35%, Platelet count 95,000/mm3, AST 200 units/L, ALT 25 units/L, Total bilirubin 1.8 mg/dL, Urine 2+ protein. Vital Signs: BP 158/100 mm Hg (0900), 162/110 mm Hg (1000), HR 90-95/min, RR 16-20/min, Temp 37°C, O2 sat 96-98%.
The nurse should first address the client's ___ followed by the client's ___
- A. Blood pressure; Platelet count
- B. Respiratory rate; Hematocrit
- C. Deep tendon reflexes; Peripheral edema
- D. Platelet count; Hematocrit
Correct Answer: A
Rationale: Severe hypertension (162/110 mm Hg) risks stroke and eclampsia, requiring immediate antihypertensive treatment, followed by addressing low platelet count (95,000/mm³) indicating HELLP syndrome and bleeding risk.
A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.
Which of the following actions should the nurse plan to take?
- A. Limit the client's daily fluid intake
- B. Encourage the client to wear a bra that is loose fitting
- C. Encourage the client to continue to breastfeed.
- D. Prepare the client for an abdominal sonogram
Correct Answer: C
Rationale: Continued breastfeeding prevents milk stasis and reduces the risk of abscess formation in mastitis.
A nurse is caring for a client who inquires about available methods of contraception.
Which of the following actions should the nurse take?
- A. Collect a dietary history
- B. Perform unbiased teaching
- C. Select the best method of contraception for the client
- D. Assess the client's socioeconomic status.
Correct Answer: B
Rationale: Providing comprehensive, nonjudgmental education on all contraceptive methods allows the client to make an informed decision based on their preferences and needs.
A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Administer NSAIDs every 4 to 6 hr.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Have the client ambulate as often as possible.
Correct Answer: D
Rationale: Early and frequent ambulation promotes circulation, reducing venous stasis and the risk of thrombophlebitis.
A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Suggest the client apply warm compresses to the affected breast
- B. Tell the client to apply hydrocortisone ointment to the affected area of the breast
- C. Encourage the client to limit oral fluid intake to decrease milk production
- D. Recommend the client avoid wearing a nursing bra until symptoms resolve
Correct Answer: A
Rationale: Warm compresses relieve pain, improve circulation, and promote milk flow, aiding in clearing the infection and reducing engorgement.