Nokea
A nurse is contributing to the plan of care for a newborn who requires phototherapy for hyperbilirubinemia.
Which of the following interventions should the nurse recommend including in the plan?
- A. Reposition the newborn every 2 to 3 hr.
- B. Give the newborn 30 mL of distilled water after each feeding
- C. Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
- D. Monitor the newborn's blood glucose level every 2 hr
Correct Answer: A
Rationale: Repositioning every 2-3 hours ensures all skin areas are exposed to phototherapy light, enhancing bilirubin breakdown.
You may also like to solve these questions
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 nurse my baby for 5 to 10 minutes on each breast.
- B. I will make sure that just the nipple is in my baby's mouth.
- C. I will lay my baby on a pillow at the level of my breast.
- D. I will apply vitamin E oil to my nipples after each feeding.
Correct Answer: C
Rationale: Positioning the baby at breast level with a pillow promotes a comfortable latch and effective feeding.
Vital Signs: Blood pressure 132/82 mm Hg, Heart rate 82/min, Respiratory rate 16/min, Temperature 37.1°C (98.8°F), Oxygen saturation 98% on room air. Nurses' Notes: Client reports, 'My baby is not moving as much as usual.' Fetal heart rate 142/min with minimal variability, no accelerations noted in 20 min. External fetal monitor applied, uterine contractions every 5 to 7 min lasting 50 to 60 sec, moderate intensity.
Which of the following actions should the nurse take next? Select all that apply.
- A. Assist the client to a lateral position
- B. Increase the rate of maintenance IV fluid.
- C. Palpate uterine tone to assess for tachysystole
- D. Initiate oxytocin intravenously.
- E. Perform a vaginal exam.
Correct Answer: A,B,C
Rationale: Repositioning to a lateral position improves uteroplacental blood flow, increasing IV fluid enhances perfusion, and palpating uterine tone checks for tachysystole, all addressing fetal heart rate deceleration.
History and Physical: Repeat caesarean birth 3 days ago, mastitis. Vital Signs: BP 130/84 mm Hg, HR 106/min, RR 20/min, Temp 38.94°C. Assessment: WBC 28,000/mm3, Hgb 13 g/dL, Hct 37%, redness/warmth in left breast, cracked nipples, body aches, chills, headache, breast tenderness.
The nurse is collecting data from the client 24 hr later. How should the nurse interpret the findings?
- A. Purulent nipple discharge: Sign of potential worsening condition
- B. Moderate lochia rubra: Unrelated to diagnosis
- C. Client reports decreased level of pain: Sign of potential improvement
- D. WBC count 35,000/mm3: Sign of potential worsening condition
- E. Temperature 38.4° C (101.1° F): Sign of potential improvement
- F. Hgb 12 g/dL: Unrelated to diagnosis
Correct Answer: A,C,D,E
Rationale: Purulent discharge and increased WBC suggest worsening mastitis, while decreased pain and lower temperature indicate improvement. Lochia and hemoglobin are unrelated to mastitis.
A nurse is assisting with the care of a client who is in labor and has an epidural infusion for pain management. The client's blood pressure is 80/40 mm Hg.
Which of the following actions should the nurse take?
- A. Give a bolus of lactated Ringer's
- B. Assist the client to empty her bladder.
- C. Place the client in knee chest position.
- D. Administer methylergonovine IM.
Correct Answer: A
Rationale: A bolus of lactated Ringer's increases intravascular volume, stabilizing blood pressure caused by epidural-induced vasodilation.
A nurse is reinforcing teaching with a client who is pregnant and does not consume dairy products.
Which of the following food options should the nurse recommend as the best source of dietary calcium?
- A. 1 cup sweet white corn
- B. 1 cup kale
- C. 1 baked potato
- D. 1 large banana
Correct Answer: B
Rationale: Kale is a rich plant-based source of calcium, providing approximately 90 mg per cup, ideal for those avoiding dairy.