Nokea
While caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse should notify the health care provider if which of the following is noted?
- A. Bronze-colored skin.
- B. Maculopapular chest rash.
- C. Urine specific gravity of 1.018.
- D. Absent Moro reflex.
Correct Answer: A
Rationale: Bronze-colored skin is a potential complication of phototherapy and should be reported to the health care provider.
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A 28-year-old multigravida at 37 weeks' gestation arrives at the emergency department with a blood pressure of 160/104 mm Hg and +3 reflexes without clonus. The client is diagnosed with severe preeclampsia. The nurse collaborates with the health care provider to develop a plan of care that care will first include:
- A. Administration of glucocorticoids(Betamethasone).
- B. Vaginal or cesarean delivery of the fetus.
- C. Prevention of seizures with phenytoin (Dilantin).
- D. Reduction of fluid retention with thiazides.
Correct Answer: B
Rationale: Delivery is the definitive treatment for severe preeclampsia.
The nurse prepares a client for lumbar epidural anesthesia. Before anesthesia administration, the nurse instructs the client to assume which of the following positions?
- A. Sitting with back arched.
- B. Lying flat on back.
- C. Side-lying with knees bent.
- D. Prone with head elevated.
Correct Answer: A
Rationale: The sitting position with the back arched (e.g., 'shrimp' position) provides optimal access to the lumbar spine for epidural placement. Other positions do not facilitate needle insertion as effectively.
A primiparous client diagnosed with cystitis at LIM 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breast-feed my baby?" The nurse should tell the client:
- A. You can continue to breast-feed as long as you want to do so.
- B. Alternate your breast-feeding with formula feeding to help you rest.
- C. You'll need to discontinue breast-feeding until the antibiotic therapy is stopped.
- D. You'll need to modify your technique by manually pumping your breasts.
Correct Answer: A
Rationale: Ampicillin is generally safe for breastfeeding, allowing the client to continue without interruption.
A neonate born at 29 weeks' gestation received nasal continuous positive airway pressure. The neonate is receiving oxygen at 1 L/minute via nasal cannula at a fraction of inspired oxygen (FiO₂) of 0.23. The pulse oximetry reading is 70% saturation. In which order of priority from first to last should the nurse take these actions?
- A. Increase the $\mathrm{FiO}_2$.
- B. Make sure the pulse oximeter is correlating to the heart rate.
- C. Assess the neonate for color.
- D. Assess the neonate for respiratory effort.
Correct Answer: B,C,D,A
Rationale: First, ensure the pulse oximeter is accurate (B). Then, assess clinical signs like color (C) and respiratory effort (D). Finally, adjust $\mathrm{FiO}_2$ (A) if needed based on findings.
While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?
- A. Pain in her calf.
- B. Dyspnea.
- C. Hypertension.
- D. Bradycardia.
Correct Answer: B
Rationale: Dyspnea may indicate a pulmonary embolism, a life-threatening complication requiring immediate attention.