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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 hours.
- B. Give the newborn 30 ml of distilled water after each feeding.
- C. Monitor the newborn's blood glucose level every hour.
- D. Apply a water-based ointment to the newborn's skin every 6 hours.
Correct Answer: A
Rationale: Repositioning the newborn every 2 hours ensures even exposure to phototherapy light, preventing skin breakdown and effectively reducing bilirubin levels.
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A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.
Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?
- A. Have the client ambulate as often as possible.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Administer NSAIDs every 6 to 8 hours.
Correct Answer: A
Rationale: Ambulation promotes venous return, preventing blood stasis and reducing thrombophlebitis risk after cesarean birth.
Nurses' Notes: The newborn is lying in a bassinet, lightly swaddled. Jitteriness observed when disturbed, weak cry, mottled extremities, mild acrocyanosis. Respirations rapid but unlabored. No lethargy, no feedings since birth. Vital Signs: Heart rate: 156/min, Respiratory rate: 64/min, Temperature: 36.1°C (97.0°F), Oxygen saturation: 96% on room air, Blood glucose level: 30 mg/dL.
Complete the diagram by dragging from the choices below to specify: Condition, Actions to Take, Parameters to Monitor (2 Correct). Condition Choices: A. Hypoglycemia, B. Congenital heart defect, C. Neonatal sepsis, D. Neonatal abstinence syndrome. Actions: A. Obtain a capillary blood glucose reading, B. Feed the newborn immediately with breastmilk or formula, C. Administer IV glucose as prescribed, D. Initiate phototherapy, E. Place under a radiant warmer. Parameters: A. Blood glucose levels, B. Respiratory effort, C. Serum bilirubin levels, D. Skin integrity, E. Oxygen saturation.
- A. Hypoglycemia
- B. Obtain a capillary blood glucose reading
- C. Feed the newborn immediately with breastmilk or formula
- D. Blood glucose levels
- E. Respiratory effort
Correct Answer: A,A,B,A,B
Rationale: Low glucose (30 mg/dL) and jitteriness indicate hypoglycemia; feeding and glucose checks address it; glucose and respiratory effort monitor progress.
A nurse is assisting with the admission of a client who has hyperemesis gravidarum.
Which of the following laboratory tests is the priority to complete?
- A. Urinalysis for ketones.
- B. Serum bilirubin.
- C. Liver enzymes.
- D. Complete blood count.
Correct Answer: A
Rationale: Urinalysis for ketones is the priority to assess dehydration and nutritional status, critical in managing hyperemesis gravidarum.
A nurse in a provider's office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.
Which of the following manifestations is the priority?
- A. Maternal temperature 38.3°C (101°F).
- B. Fetal heart tones 98/min.
- C. Foul-smelling vaginal discharge.
- D. Amniotic fluid with meconium noted.
Correct Answer: B
Rationale: Fetal heart tones at 98/min are significantly lower than the normal range (110-160/min), indicating fetal distress and requiring immediate intervention.
A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.
Which of the following discomforts should the nurse include in the teaching?
- A. Tingling in the fingers.
- B. Round ligament pain.
- C. Urination urgency and frequency.
- D. Perineal discomfort and pressure.
Correct Answer: C
Rationale: Urination urgency and frequency are common first-trimester discomforts due to hormonal changes and uterine pressure on the bladder.