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. Weigh the newborn's wet diaper.
- B. Determine the newborn's respiratory rate.
- C. Auscultate the newborn's bowel sounds.
- D. Swaddle the newborn impretermn blankets.
Correct Answer: B
Rationale: Determining the respiratory rate is critical first, as neonatal abstinence syndrome can cause respiratory distress, requiring immediate intervention for the newborn's safety.
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A nurse is collecting data from a client who is at 26 weeks of gestation and whose last appointment was 1 month ago.
Which of the following findings should the nurse report to the provider?
- A. Pedal edema
- B. BP of 132/84 mm Hg
- C. Weight gain of 1 kg (2.2 lb)
- D. Double vision
Correct Answer: D
Rationale: Double vision can indicate preeclampsia or other serious conditions in pregnancy, requiring prompt reporting for further evaluation and management.
A nurse is reinforcing teaching with a client who is at 10 weeks of gestation regarding the purposes of laboratory tests.
Which of the following statements by the client indicates an understanding of the teaching?
- A. White blood cell count is an indicator of anemia.
- B. Urine specific gravity identifies my risk for pregnancy induced hypertension
- C. Platelet count identifies if I am at risk for bleeding
- D. Sedimentation rate checks for signs of cancer
Correct Answer: C
Rationale: Platelet count identifies bleeding risk by assessing clotting ability, a key concern in pregnancy, showing the client understands the test's purpose accurately.
A nurse is reviewing the facility protocol about newborn identification and safety with a new parent. Which of the following information should the nurse include?
- A. You should check the identity of individuals who come to remove your baby from the room
- B. We will scan your baby's identification bracelet each time check on him
- C. We will match the bracelet on your baby with his footprint record each shift
- D. Your baby will wear an electronic bracelet when he is out of your room
Correct Answer: A
Rationale: It's crucial for parents to verify the identity of anyone who comes to take their baby out of the room. This helps ensure the baby's safety and prevents unauthorized individuals from taking the baby. Hospital staff usually wear identification badges, and parents should be encouraged to ask for and verify this identification.
A nurse is caring for a client who had a vaginal delivery 4 hr ago and reports perineal pain of 6 on a scale of 0 to 10.
Which of the following actions should the nurse take?
- A. Offer an ice pack to the client during the first 24 hr.
- B. Apply a corticosteroid cream to the perineal area twice daily.
- C. Increase the client's fluid intake for 48 hr.
- D. Catheterize the client's bladder.
Correct Answer: A
Rationale: Offering an ice pack reduces inflammation and numbs the perineal area, providing effective pain relief in the immediate postpartum period after vaginal delivery.
A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level.
Which of the following foods should the nurse recommend the client increase in her diet?
- A. Peanut butter
- B. Avocados
- C. Yogurt
- D. Long-grain rice
Correct Answer: C
Rationale: Yogurt is an excellent calcium source, vital for fetal bone development and maternal health, making it the best recommendation for low calcium levels.