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The nurse is preparing to care for a newborn receiving
phototherapy. Which interventions should be included in the plan
of care? Select all that apply.
1. Avoid stimulation.
2. Decrease fluid intake.
3. Expose all of the newborn's skin.
4. Monitor skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches.
4. Monitor skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches.
The nurse develops a plan of care for a woman with human
immunodeficiency virus infection and her newborn. The nurse
should include which intervention in the plan of care?
1. Monitoring the newborn's vital signs routinely
2. Maintaining standard precautions at all times while caring for the
newborn
3. Initiating referral to evaluate for blindness, deafness,
learning problems, or behavioral problems
4. Instructing the breast-feeding mother regarding the
treatment of the nipples with nystatin ointment
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2. Maintaining standard precautions at all times while caring for
the newborn
The nurse is planning care for a newborn of a mother with
diabetes mellitus. What is the priority nursing consideration for
this newborn?
1. Developmental delays because of excessive size
2. Maintaining safety because of low blood glucose levels
3. Choking because of impaired suck and swallow reflexes
4. Elevated body temperature because of excess fat and glycogen
2. Maintaining safety because of low blood glucose levels
Which statement reflects a new mother's understanding of the
teaching about the prevention of newborn abduction?
1. "I will place my baby's crib close to the door."
2. "Some health care personnel won't have name badges."
3. "It's OK to allow the unlicensed assistive personnel to carry my
newborn to the nursery."
4. "I will ask the nurse to attend to my infant if I am napping and
my husband is not here."
4. "I will ask the nurse to attend to my infant if I am napping
and my husband is not here." The nurse prepares to administer
a vitamin K injection to a newborn, and the mother asks the
nurse why her infant needs the injection. What best response
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should the nurse provide?
1. "Your newborn needs vitamin K to develop immunity."
2. "The vitamin K will protect your newborn from being jaundiced."
3. "Newborns have sterile bowels, and vitamin K promotes the
growth of bacteria in the bowel."
4. "Newborns are deficient in vitamin K, and this injection prevents
your newborn from bleeding."
4. "Newborns are deficient in vitamin K, and this injection prevents
your newborn from bleeding." The nurse is monitoring a client who
is receiving oxytocin (Pitocin) to induce labor. Which assessment
finding would cause the nurse to immediately discontinue the
oxytocin infusion?
1. Fatigue
2. Drowsiness
3. Uterine hyperstimulation
4. Early decelerations of the fetal heart rate
3. Uterine hyperstimulation
A pregnant client is receiving magnesium sulfate for the
management of preeclampsia. The nurse determines that the
client is experiencing toxicity from the medication if which
finding is noted on assessment?
1. Proteinuria of 3+
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2. Respirations of 10 breaths/minute
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