A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level.
Which of the following actions should the nurse
... [Show More] take? - D. Use a photometer to monitor the lamp's
energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving
the appropriate amount to be effective.
A nurse is assessing a client at 34 weeks gestation who has a mild placental abruption. Which of the
following findings should the nurse expect? - Dark red vaginal bleeding
The nurse should expect this client with a mild placental abruption to have minimal dark red vaginal
bleeding.
A nurse is assessing a newborn and notes an axillary temperature of 96.9°F (36°C). Which of the
following actions should the nurse perform? - Correct Answer:
B.
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heat through increased muscular and metabolic activity.
This process increases glucose consumption and puts the newborn at risk of hypoglycemia.
Incorrect Answers:
A. The nurse should not obtain a rectal temperature from a newborn due to the risk of rectal
perforation. Instead, the nurse should obtain an axillary temperature.
C. Bathing a newborn will increase heat loss. The infant should not be bathed until the temperature has
stabilized within the normal range.D. Placing the infant in front of a heater vent can incur heat loss through convection. Additionally, there
is a potential fire risk from the bassinet linens and the vent.
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate. The client
begins to show indications of magnesium sulfate toxicity. Which of the following medications should the
nurse prepare to administer? - Correct Answer:
C. Calcium gluconate
The nurse should discontinue the magnesium sulfate infusion immediately and prepare to administer
calcium gluconate IV to reverse the effects of magnesium sulfate and to prevent cardiac and respiratory
arrest.
Incorrect Answers:
A. Protamine sulfate helps reverse the effects of heparin, not magnesium sulfate.
B. Naloxone is an opioid reversal agent. It does not reverse the effects of magnesium sulfate.
D. Flumazenil reverses the effects of benzodiazepines such as lorazepam and alprazolam, not
magnesium sulfate.
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast
discomfort relief measures. Which of the following pieces of information should the nurse include? -
Correct Answer:
"Place fresh cabbage leaves on your breasts."
After 3 days postpartum, the client's breasts can become swollen and distended because of congestion
of the vascular structures of the breasts.
Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort.
The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts.Leaves should be replaced when they become wilted.
Incorrect Answers:
A. The client should be instructed to wear a tight-fitting bra or breast binders to alleviate engorgement
and swelling.
C. Application of warmth to the breasts should be avoided because heat can stimulate milk production.
An ice pack should be used to relieve engorged breasts.
D. Milk should not be expressed from the breasts. This intervention would increase milk production
rather than decrease it.
A nurse is educating a client who is at 10 weeks gestation and reports frequent nausea and vomiting.
Which of the following statements should the nurse include in the teaching? - Correct Answer:
D.
"You should eat dry foods that are high in carbohydrates when you wake up."
The nurse should instruct the client to eat foods that are high in carbohydrates such as dry toast or
crackers upon waking or when nausea occurs.
Incorrect Answers:
A. The nurse should instruct the client to eat foods served at cool temperatures to decrease nausea and
vomiting.
B. The nurse should instruct the client to avoid brushing her teeth immediately after eating to decrease
vomiting.
C. The nurse should instruct the client to eat salty and tart foods during periods of nausea.
A nurse is providing postpartum discharge teaching for a client who is breastfeeding. The client states,
"I've heard that I can't use any birth control until I stop breastfeeding." Which of the following responses
should the nurse make? - [Show Less]