1. The nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting. Which of the following findings should the nurse
... [Show More] identify as an indication that the client has hyperemesis gravidarum? a. Ketonuria i. Occurs due to the breakdown of fat secondary to malnutrition or starvation 2. The nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal examination. Which of the following findings should the nurse report to the provider? a. Blurred vision i. An indication that the client might have preeclampsia 3. The nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling efforts. Which of the following neonatal data collection tools should the nurse expect to complete? a. Neonatal abstinence scoring system i. Exhibiting manifestations of opioid withdrawal and should be screened ii. Additional manifestations of withdrawal include restlessness, tremors, increased muscle tone, and an exaggerated Moro reflex 4. The nurse is caring for a newborn who is receiving phototherapy. Which of the following actions should the nurse take? a. Place an opaque mask over the newborn’s eyes i. To prevent damage to the retinas – remove mask for feedings 5. The nurse is assisting in the care of a newborn immediately following birth. Which of the following images should the nurse identify as an indication that the newborn was a myelomeningocele? a. First picture – exposed spinal cord and fluid filled sac, priority intervention is to maintain the integrity of the sac i. Myelomeningocele occurs when the neural tube fails to close, and the meninges and spinal cord herniate 1. Defect most often occurs in the lumbar area and may be covered by a thin membranous sac 6. The nurse is collecting data from a newborn who is 8 hr old. Which of the following findings should the nurse report to the provider? a. Apical heart rate of 90/min while crying i. Is below the expected reference range of 110-160 bpm for a newborn; 80-100 bpm while sleeping; and up to 180 bpm while crying 7. The nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn. The client reports perineal pain of 6 on a scale from 0-10. The nurse also notes mild perineal edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the right. Which of the following action is the nurse’s priority? a. Help the client ambulate to the toilet i. Greatest risk is postpartum hemorrhage from uterine atony; help client to urinate & completely empty the bladder, which will allow the uterus to contract
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