Nokea
A nurse is checking the reflexes of a newborn.
Which of the following actions should the nurse use to elicit the Babinski reflex?
- A. Stroke upward on the lateral aspect of the sole of the newborn's foot.
- B. Place the newborn supine and apply pressure to the soles of the feet.
- C. Pull the newborn up by the wrist from a supine position
- D. Touch the corner of the newborn's mouth
Correct Answer: A
Rationale: The Babinski reflex is elicited by stroking the lateral sole of the foot, causing dorsiflexion of the big toe and fanning of other toes in newborns.
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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 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. Urine specific gravity identifies my risk for pregnancy-induced hypertension.
- B. White blood cell count is an indicator of anemia.
- 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 assesses clotting function, identifying bleeding risk in conditions like gestational thrombocytopenia.
A nurse in a provider's office is reinforcing teaching with a client who is pregnant and is scheduled for a nonstress test.
Which of the following statements should the nurse make?
- A. You will not be able to eat or drink anything for 8 hours prior to the test.
- B. You will receive medication through an IV line to stimulate contractions.
- C. You will press the provided button when you feel the baby moving during the test.
- D. You will be required to lie flat on your back for the duration of the test.
Correct Answer: C
Rationale: During a nonstress test, the client presses a button when they feel fetal movement to monitor fetal heart rate response, assessing fetal well-being. No fasting, IV medication, or lying flat is required.
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. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.
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.