Nokea
Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?
- A. Encourage high-calorie meals
- B. Administer intravenous fluids
- C. Provide frequent small meals
- D. Limit fluid intake
Correct Answer: B
Rationale: Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration.
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A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct Answer: A
Rationale: Contractions that are too frequent or prolonged can lead to uterine hyperstimulation, which can compromise fetal oxygenation. The nurse should stop the oxytocin infusion to reduce contraction frequency and intensity.
A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?
- A. Encourage the mother to breastfeed the newborn
- B. Gavage feed 60 mL (2 oz) of glucose water
- C. Administer 10 mL of D5W via IV
- D. Recheck the glucose level in 2 hr
Correct Answer: A
Rationale: Encouraging the mother to breastfeed is appropriate, as breastfeeding can quickly raise blood glucose levels in newborns. A level of 45 mg/dL is often acceptable but should be monitored closely.
A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Administer oral feedings
- B. Measure abdominal girth
- C. Position the newborn prone
- D. Apply warm compresses to the abdomen
Correct Answer: B
Rationale: Measuring abdominal girth is important in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). Other interventions include withholding oral feedings and providing IV fluids or nutrition.
A nurse is teaching a client who is Rh-negative about Rh (D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. If my partner is Rh-negative, I will not receive the shot.
- B. I will receive the shot after delivery if my baby is Rh-negative.
- C. I should not receive any immunizations for 3 months after the shot.
- D. This shot may be given after birth to protect future pregnancies.
Correct Answer: D
Rationale: The client's statement correctly reflects that Rh immune globulin is administered after delivery to prevent sensitization in future pregnancies, especially if the baby is Rh-positive.
A nurse is providing teaching to a client who is 32 weeks pregnant and has a diagnosis of placenta previa. Which of the following instructions should the nurse include?
- A. Limit physical activity
- B. Monitor fetal movements daily
- C. Call the healthcare provider if contractions begin
- D. All of the above
Correct Answer: D
Rationale: Clients with placenta previa are at increased risk for bleeding and preterm labor. They should limit physical activity, monitor fetal movements, and notify their provider if they experience any contractions or signs of labor.