Nokea
Which of the following would be most important for the nurse to encourage in a primiparous client diagnosed with endometritis who is receiving intravenous antibiotic therapy?
- A. Ambulate to the bathroom frequently.
- B. Discontinue breast-feeding temporarily.
- C. Maintain bed rest in Fowler's position.
- D. Restrict visitors to prevent contamination.
Correct Answer: C
Rationale: Fowler's position promotes drainage of uterine secretions, aiding recovery from endometritis.
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After instructing a multigravid client at 10 weeks' gestation diagnosed with chronic hypertension about the need for frequent prenatal visits, the nurse determines that the instructions have been successful when the client states which of the following?
- A. "I may develop hyperthyroidism because of my high blood pressure."
- B. "I need close monitoring because I may have a small-for-gestational-age infant."
- C. "It's possible that I will have excess amniotic fluid and may need a cesarean section."
- D. "I may develop placenta accreta, so I need to keep my clinic appointments."
Correct Answer: B
Rationale: Chronic hypertension increases the risk of having a small-for-gestational-age infant.
A viable male neonate delivered to a 28-year-old multiparous client by cesarean delivery because of placenta previa is diagnosed with respiratory distress syndrome. Which of the following would the nurse explain as the factor placing the neonate at the greatest risk for this syndrome?
- A. Mother's development of placenta previa.
- B. Neonate delivered preterm.
- C. Mother receiving analgesia 4 hours before delivery.
- D. Neonate with sluggish respiratory efforts after delivery.
Correct Answer: B
Rationale: Preterm delivery is the primary risk factor for RDS due to immature lung development and insufficient surfactant production.
The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?
- A. Hypoglycemia.
- B. Hyperbilirubinemia.
- C. Hemorrhage.
- D. Polycythemia.
Correct Answer: C
Rationale: Phytonadione (vitamin K) is administered to newborns to prevent hemorrhagic disease due to low vitamin K levels, which are necessary for blood clotting.
A 24-year-old primipara who has delivered a healthy neonate in the hospital's birthing center plans to bottle-feed her neonate. When developing the nutritional teaching plan for the mother, the nurse should determine that the number of calories required by the neonate each day per pound of body weight is which of the following?
- A. 30 to 35.
- B. 40 to 45.
- C. 50 to 55.
- D. 60 to 65.
Correct Answer: C
Rationale: Neonates require approximately 50-55 calories per pound of body weight daily for growth and development.
The physician orders whole blood replacement for a multigravid client with abruptio placentae. Before administering the intravenous blood product, the nurse should first:
- A. Validate client information and the blood product with another nurse.
- B. Check the vital signs before transfusing over 5 to 6 hours.
- C. Ask the client if she has ever had any allergies.
- D. Administer 100 mL of 5% dextrose solution intravenously.
Correct Answer: A
Rationale: Validating client information and blood product is essential to prevent transfusion errors.