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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. Weigh the newborn's wet diaper.
- C. Auscultate the newborn's bowel sounds.
- D. Determine the newborn's respiratory rate.
Correct Answer: D
Rationale: Determining the respiratory rate first ensures airway and breathing stability, a critical initial step in managing neonatal abstinence syndrome.
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Vital Signs 0830: Temperature: 36.9°C (98.4°F), Heart rate: 89/min, Respiratory rate: 16/min, Blood pressure: 110/60 mm Hg, Oxygen saturation: 97% on room air. 0930: Temperature: 38.2°C (100.8°F), Heart rate: 90/min, Respiratory rate: 20/min, Blood pressure: 120/68 mm Hg, Oxygen saturation: 98% on room air. A nurse is caring for a 27-year-old female client at 32 weeks gestation in the labor and delivery unit admitted for evaluation of a suspected infection during labor.
For each potential provider prescription, click to specify whether the prescription is anticipated or contraindicated for the client: A. Betamethasone 12 mg IM now and repeat in 24 hr, B. Position the client supine, C. Terbutaline 0.25 mg Subcutaneous now, D. Collect a urine sample.
- A. Betamethasone 12 mg IM now and repeat in 24 hr (Anticipated)
- B. Position the client supine (Contraindicated)
- C. Terbutaline 0.25 mg Subcutaneous now (Anticipated)
- D. Collect a urine sample (Anticipated)
Correct Answer: A,C,D
Rationale: Betamethasone aids fetal lung maturity, terbutaline delays preterm labor, and urine sample assesses infection; supine position risks uterine perfusion.
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. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
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, an opioid analgesic that depresses the central nervous system, causing drowsiness.
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. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 4 to 6 hours.
Correct Answer: A
Rationale: Encouraging ambulation stimulates circulation, preventing blood clots and reducing thrombophlebitis risk post-cesarean.
A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will make sure that just the nipple is in my baby’s mouth.
- B. I will apply vitamin E oil to my nipples after each feeding.
- C. I will nurse my baby for 5 to 10 minutes on each breast.
- D. I will lay my baby on a pillow at the level of my breast.
Correct Answer: D
Rationale: Laying the baby on a pillow at breast level ensures proper positioning and latch, key to successful breastfeeding.