Question 1:
A nurse is assessing a client who has preeclampsia during a prenatal visit.
Which of the following findings should the nurse report to the
... [Show More] provider?
A. Urine protein of 3+
B. Deep tendon reflexes of 2+
C. Hemoglobin 13 g/dL
D. Blood glucose 110 mg/dL
Show correct answer and explanation
Explanation
Answer is: a. Urine protein of 3+
Explanation:
• Urine protein of 3+ indicates severe proteinuria, which is a sign of
preeclampsia and can lead to kidney damage. The nurse should report
this finding to the provider as it may require medication or delivery
intervention.
• Deep tendon reflexes of 2+ are normal and do not indicate preeclampsia.
The nurse should monitor the client for hyperreflexia, which is a sign of
increased neuromuscular irritability and can precede seizures.
• Hemoglobin 13 g/dL is within the normal range for a pregnant client and
does not indicate preeclampsia. The nurse should monitor the client for
anemia, which can cause maternal and fetal complications.
• Blood glucose 110 mg/dL is slightly elevated but not diagnostic of
gestational diabetes, which is a different condition from preeclampsia. The
nurse should advise the client to follow a balanced diet and exercise
regimen and to undergo a glucose tolerance test at 24 to 28 weeks of
gestation.
.
Question 2:
A nurse is planning care for a newborn who is scheduled to start phototherapy
using a lamp. Which of the following actions should the nurse include in the
plan?
A. Give the newborn 1 oz of glucose water every 4 hr.
B. Apply a thin layer of lotion to the newborn's skin every 8 hr.
C. Ensure the newborn's eyes are closed beneath the shield.
D. Dress the newborn in a thin layer of clothing during therapy.
Show correct answer and explanation
Explanation
The correct answer is choice C, Ensure the newborn's eyes are closed beneath
the shield. Phototherapy is a treatment used to reduce high bilirubin levels in
newborns. It involves exposing the newborn's skin to special lights, which helps to
break down the excess bilirubin in the blood. It is important to ensure that the
newborn's eyes are closed beneath the shield to prevent damage to the eyes
from the bright lights. Giving the newborn 1 oz of glucose water every 4 hr,
applying lotion to the newborn's skin every 8 hr, and dressing the newborn in a
thin layer of clothing during therapy are not indicated interventions during
phototherapy.
Question 3:
A nurse is performing an assessment for a newborn and notes breast tissue
that has a flat areola with no bud. The nurse should identify that this finding
indicates which of the following conditions?
A. Decreased maternal hormones during pregnancy
B. Preterm gestational age
C. Ambiguous secondary sex characteristics
D. Congenital anomaly
Show correct answer and explanation
Explanation
Answer and explanation
The correct answer is choice A, Decreased maternal hormones during
pregnancy. Breast tissue with a flat areola and no bud is a normal finding in
newborns and indicates that the infant did not receive significant amounts of
maternal hormones during pregnancy. Preterm gestational age, ambiguous
secondary sex characteristics, and congenital anomalies would not typically
present with this finding.
Question 4:
A nurse is caring for a newborn immediately following birth and notes a large
amount of mucus in the newborn's mouth and nose. Identify the sequence the
nurse should follow when performing suction with a bulb syringe.
A. Assess the newborn for reflex bradycardia.
B. Compress the bulb syringe.
C. Use the bulb syringe to suction the newborn's nose.
D. Place the bulb syringe in the newborn's mouth.
Show correct answer and explanation
Explanation
The correct answer is choice B, D, C, A. The sequence the nurse should follow
when performing suction with a bulb syringe is to compress the bulb syringe,
place the bulb syringe in the newborn's mouth, use the bulb syringe to suction
the newborn's nose, and then assess the newborn for reflex bradycardia. That
sequence is the most effective way to suction a newborn's mouth and nose, as it
ensures that the newborn's airway is cleared of mucus before assessing fo [Show Less]