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. Monitor the newborn's blood glucose level every 2 hr.
- C. Give the newborn 30 ml of distilled water after each feeding.
- D. Apply a water-based ointment to the newborn's skin every 4 to 6 hr.
Correct Answer: A
Rationale: Repositioning the newborn every 2 to 3 hours helps ensure uniform exposure to the phototherapy lights, maximizing the effectiveness of the treatment. This prevents uneven distribution of light and reduces the risk of pressure ulcers or skin breakdown from prolonged immobility.
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A nurse is reinforcing teaching about car seat safety with a parent of a newborn.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should place my baby in the car seat at a 90-degree angle.
- B. I will place a thick, soft pad behind my baby's back.
- C. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
- D. I will place the retainer clip at the level of my baby's armpits
Correct Answer: D
Rationale: Placing the retainer clip at the armpit level ensures proper harness positioning, providing optimal protection in a crash, indicating understanding of car seat safety.
A nurse is reinforcing teaching about preventing mastitis with a client who is breastfeeding.
Which of the following instructions should the nurse include?
- A. Wear an underwire bra between feedings.
- B. You should use a breast pump if you plan to return to work.
- C. Wash your nipples with soap and water daily.
- D. Cover your breasts immediately after feedings.
Correct Answer: B
Rationale: Using a breast pump prevents engorgement when returning to work, reducing mastitis risk by maintaining milk flow and supply.
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. Diuresis
- B. Fever
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Nalbuphine hydrochloride is an opioid analgesic used for pain relief during labor. Sedation is a common adverse effect of opioid medications, including nalbuphine, due to central nervous system depression, leading to drowsiness and decreased consciousness.
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 be required to lie flat on your back for the duration of the test
- C. You will receive medication through an IV line to stimulate contractions.
- D. You will press the provided button when you feel the baby moving during the test.
Correct Answer: D
Rationale: Pressing a button when feeling fetal movement during a nonstress test correlates movement with heart rate changes, assessing fetal well-being accurately.
A nurse is caring for a client who is pregnant and has a vaginal culture that is positive for chlamydia.
Which of the following medications should the nurse plan to administer?
- A. Acyclovir
- B. Metronidazole
- C. Tetracycline
- D. Amoxicillin
Correct Answer: D
Rationale: Amoxicillin is a safe and effective antibiotic for treating chlamydia in pregnant women, avoiding tetracyclines which are contraindicated due to fetal risks.