Nokea
Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?
- A. Keep the neonate's eyes completely covered.
- B. Use a regular diaper on the neonate.
- C. Offer feedings every 4 hours.
- D. Check the oral temperature every 8 hours.
Correct Answer: A
Rationale: Keeping the neonate's eyes completely covered protects them from potential retinal damage during phototherapy.
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For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:
- A. Exhaustion.
- B. Chills and fever.
- C. Fluid overload.
- D. Meconium-stained fluid.
Correct Answer: A
Rationale: Prolonged latent phase (8 hours) in a primigravid client can lead to maternal exhaustion due to sustained effort and lack of progress, impacting labor stamina. Chills/fever, fluid overload, or meconium-stained fluid are less likely without specific risk factors.
For the client who is receiving intravenous magnesium sulfate for severe preeclampsia, which of the following assessment findings would alert the nurse to suspect hypermagnesemia?
- A. Decreased deep tendon reflexes.
- B. Cool skin temperature.
- C. Rapid pulse rate.
- D. Tingling in the toes.
Correct Answer: A
Rationale: Decreased deep tendon reflexes are a sign of hypermagnesemia.
A client at 4 weeks postpartum tells the nurse that she can't cope any longer and is overwhelmed by her newborn. The baby has old formula on her clothes and under her neck. The mother does not remember when she last bathed the baby and states she does not want to care for the infant. The nurse should encourage the client and her husband to call their health care provider because the mother should be evaluated further for?
- A. Postpartum blues.
- B. Postpartum depression.
- C. Poor bonding.
- D. Infant abuse.
Correct Answer: B
Rationale: Postpartum depression involves feelings of being overwhelmed and unable to care for the infant.
A 21-year-old primigravid client at 40 weeks' gestation is admitted to the hospital in active labor. The client's cervix is 8 cm and completely effaced at 0 station. During the transition phase of labor, which of the following is a priority nursing diagnosis?
- A. Impaired urinary elimination related to nothing-by-mouth status.
- B. Risk for injury related to hyperventilation and dizziness.
- C. Ineffective coping related to lack of confidence.
- D. Pain related to increasing frequency and intensity of uterine contractions.
Correct Answer: D
Rationale: During the transition phase (8–10 cm), intense and frequent contractions cause significant pain, making pain management the priority nursing diagnosis. Urinary elimination issues are less urgent, hyperventilation is a secondary concern, and coping issues are not as immediate as pain.
The physician orders 1000 mL of Ringer's Lactate intravenously over an 8-hour period for a 29-year-old primigravid client at 16 weeks' gestation with hyperemesis. The drip factor is 12 gtts/mL. The nurse should administer the IV infusion at how many drops per minute?
- A. 25 gtts/minute.
- B. 30 gtts/minute.
- C. 35 gtts/minute.
- D. 40 gtts/minute.
Correct Answer: A
Rationale: Calculation: (1000 mL * 12 gtts/mL) / (8 hours * 60 minutes) = 25 gtts/minute.