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A 3-month-old with myelomeningocele and atonic
bladder is catheterized every 4 hours to prevent urinary
retention. The home health nurse notes that the child
has developed episodes of sneezing, urticaria, watery
eyes, and a rash in the diaper area. What action is most
important for the nurse to take?
A. Auscultate the lungs for respiratory pneumonia.
B. Draw blood to analyze for streptococcal infection
C. Change to latex-free gloves when handling infant
, D. Apply zinc oxide to perineum with each diaper
change - CORRECT ANSWER -C. Change to latex-free
gloves when handling infant
The nurse is caring for a female client, a primigravida,
with preeclampsia. Findings include +2 proteinuria, BP
172/112 mmHg, facial and hand swelling, complaints of
blurry vision and a severe frontal headache. Which
medication should the nurse anticipate for this client?
A. Clonidine hydrochloride
B. Carbamazepine
C. Furosemide
D. Magnesium sulfate - CORRECT ANSWER -D.
Magnesium sulfate
,A primigravida arrives at the observation unit of the
maternity unit because thinks is in labor. The nurse
applies the external fetal heart monitor and determines
that the fetal heart rate is 140 beats/minute and the
contractions are occurring irregularly every 10 to 15
minutes. What
assessment finding confirms to the nurse that the client
is not labor at this time? - CORRECT ANSWER
Contractions decrease with walking.
A primipara has delivered a stillborn fetus at 30 weeks
gestation. To asses the parents in the grieving process
which intervention is most for the nurse to implement ?
A. explain the possible cause of the fetal demise
B. Provide a time for the parents to hold their infant in
privacy
, C. Encourage the parents to seek counseling within the
next few weeks
D. Assist the couple to request autopsy - CORRECT
ANSWER -B. provide a time for the parents to hold
their infant in privacy
What is the priority nursing assessment immediately
following the birth of an infant with esophageal atresia
and a tracheoesophageal (the) fistula ?
A. body temperature
B. level of pain
C. time of first void
D. number of vessels in the cord - CORRECT ANSWER -A.
body temperature
What is the most important assessment for the nurse to
conduct following the administration of epidural
anesthesia to a client who is at 40-weeks gestation?