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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 50 degree angle.
- B. I will place the retainer clip at the level of my baby's armpits.
- C. I will place a thick, soft pad behind my baby's back.
- D. I can turn the car seat so it faces forward when my baby weighs 15 pounds.
Correct Answer: B
Rationale: The chest clip should be at armpit level to ensure proper harness positioning for maximum safety.
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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 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.
Medical History: 24-year-old with type 1 diabetes, gravida 1 para 1, vaginal birth at 37 weeks, newborn 4.1 kg, third-degree laceration. Vital Signs: Temp 37.3°C, BP 128/82 mm Hg, HR 84/min, RR 18/min. Nurses' Notes: Fundus firm, moderate lochia, diaphoretic, clammy, weak, nauseous at 1500. Diagnostic Results: Blood glucose 120 mg/dL at 1300.
The nurse should plan to ___ and ___
- A. Draw blood for culture and sensitivity
- B. Implement seizure precautions
- C. Administer an IV bolus of dextrose 5% in water
- D. Check deep tendon reflexes
- E. Have the client drink 4 oz of regular soda
- F. Check the client's blood glucose level
Correct Answer: F,E
Rationale: Diaphoresis, weakness, and nausea suggest hypoglycemia in a diabetic client. Checking blood glucose confirms the diagnosis, and drinking soda provides fast-acting carbohydrates for a conscious client.
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 reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Lie in a left side-lying position for 30 min after meals.
- B. Eat three large meals per day.
- C. Drink a cup of black coffee before breakfast.
- D. Take sips of milk between meals.
Correct Answer: D
Rationale: Sips of milk neutralize stomach acid, relieving heartburn without overfilling the stomach.
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. Administer NSAIDs every 4 to 6 hr.
- B. Apply warm, moist packs to the client's lower legs.
- C. Apply elastic stockings before the client gets out of bed.
- D. Have the client ambulate as often as possible.
Correct Answer: D
Rationale: Early and frequent ambulation promotes circulation, reducing venous stasis and the risk of thrombophlebitis.