Nokea
Which of the following clinical findings should the nurse instruct the client to report?
- A. Increased fetal movement.
- B. Increased urinary output.
- C. Increased muscle weakness.
- D. Increased respiratory rate.
Correct Answer: C
Rationale: Increased muscle weakness is a sign of magnesium sulfate toxicity and should be reported, as it may necessitate dose adjustment. Increased fetal movement is positive, urinary output may increase normally, and respiratory rate increase is not typical.
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Which of the following clinical findings should the nurse report to the provider?
- A. Rust-stained urine.
- B. Single palmar creases.
- C. Subconjunctival hemorrhage.
- D. Transient circumoral cyanosis.
Correct Answer: B
Rationale: Single palmar creases may indicate genetic conditions like Down syndrome and should be reported for further evaluation. Rust-stained urine (urate crystals), subconjunctival hemorrhage, and transient circumoral cyanosis are common and usually benign in newborns.
Which of the following is an appropriate action for the nurse to take?
- A. Administer IV antibiotics to the newborn.
- B. Encourage the mother to breastfeed her newborn.
- C. Cleanse the newborn immediately after delivery.
- D. Initiate contact precautions for the newborn.
Correct Answer: C
Rationale: Cleansing the newborn immediately after delivery reduces the risk of HIV transmission by removing maternal blood or fluids. IV antibiotics are not routine for HIV exposure, breastfeeding is contraindicated, and contact precautions are unnecessary as HIV is not spread by casual contact.
Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn's skin every 4 hr.
- B. Give the newborn 1 oz of glucose water every 4 hr.
- C. Ensure the newborn's eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy.
Correct Answer: C
Rationale: Ensuring the newborn's eyes are closed beneath the shield protects them from light exposure during phototherapy. Lotion interferes with light penetration, glucose water is unnecessary, and clothing reduces skin exposure.
Which of the following genetic information should the nurse include in the program as a cause of hemolytic disease?
- A. The mother and the father are both Rh positive.
- B. The mother is Rh positive and the father is Rh negative.
- C. The mother is Rh negative and the father is Rh positive.
- D. The mother and the father are both Rh negative.
Correct Answer: C
Rationale: Hemolytic disease occurs when an Rh-negative mother carries an Rh-positive fetus, leading to antibody formation against fetal red blood cells. Other combinations do not cause Rh incompatibility.
Which of the following actions should the nurse take?
- A. Position the client in a knee-chest position.
- B. Administer a bolus infusion of lactated Ringer's.
- C. Give terbutaline subcutaneously.
- D. Apply oxygen via a nonrebreather face mask at 2 L/min.
Correct Answer: B
Rationale: Administering a bolus of lactated Ringer's treats hypotension by increasing blood volume, counteracting epidural-induced vasodilation. Knee-chest position, terbutaline, or low-flow oxygen are not appropriate for this scenario.