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 take?
Use a photometer to monitor thelamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the
newborn isreceiving the appropriate amount to be effective.
A nurse is assessing a client at 34 weeks’ gestationwho 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 vaginalbleeding.
A nurse is assessing a newborn and notes an axillarytemperature of 96.9°F (36°C).
Which of the following actions should the nurse perform?
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heatthrough 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 temperaturefrom 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 linensand the vent.
,A nurse is caring for a client who is in preterm laborand 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 sulfateinfusion 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 ofheparin, not magnesium
sulfate.
B. Naloxone is an opioid reversal agent. It does notreverse 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 phytoestrogensexert a therapeutic effect on
engorged breasts.
Leaves should be replaced when they becomewilted.
,Incorrect Answers::
A. The client should be instructed to wear a tight- fitting bra or breast binders to
alleviate engorgementand 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 incarbohydrates when you
wake up."
The nurse should instruct the client to eat foods thatare 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 andvomiting.
B. The nurse should instruct the client to avoidbrushing her teeth
immediately after eating to decrease vomiting.
C. The nurse should instruct the client to eat saltyand 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? - Correct
Answer:
D.
"A progestin-only pill or injection is available for usewhile you are breastfeeding."
Progestin-only injections, implants, and birth controlpills are acceptable options for
clients who are breastfeeding, although some experts recommend waiting until 6 weeks
postpartum to initiate the medication.
Incorrect Answers::
A. Breastfeeding can inhibit ovulation or prolongmenstruation; however, it is
, not a reliable and effective means of birth control. The client mayexperience an
unplanned pregnancy if she waitsuntil her periods resume before considering
birthcontrol options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended forclients who are breastfeeding due to the risk of inhibiting breast
milk production and supply.
C. Condoms and other non-hormonal birth controlmethods are appropriate for
clients who are breastfeeding; however, there are other methodsthat are also
appropriate.
A nurse is assessing a client who is receiving morphine via a patient-controlled
analgesia (PCA)pump following a cesarean birth. Which of the following findings
should the nurse report to the provider? - Correct Answer:
D.
Urine output 20 mL/hr
Opioid analgesics such as morphine can cause urinary retention. The client should have
a urinary output of at least 30 mL/hr. The nurse should reportthis finding to the
provider.
Incorrect Answers::
A. Opioid analgesics can cause respiratory depression. However, this respiratory
rate is withinthe expected reference range.
B. This temperature is within the expected referencerange.
C. Dizziness is a common adverse effect of receivingopioid analgesics. The nurse
should instruct the client to sit on the side of the bed before getting up,assist the client
with ambulation, and implement general safety measures. However, it is not necessary
to report this finding to the provider.
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and
is scheduled foran external cephalic version. Which of the following statements should
the nurse make? - Correct Answer:
B."You will receive a medication to relax your uterusprior to the procedure."
A client who is scheduled to undergo an external cephalic version often receives a
tocolytic prior to the procedure to allow the uterus to relax. A relaxeduterus allows
an easier version by the provider.
elevated bilirubin level. Which of the following actions should the nurse take?
Use a photometer to monitor thelamp's energy
The nurse should monitor the lamp's energy throughout the therapy to ensure the
newborn isreceiving the appropriate amount to be effective.
A nurse is assessing a client at 34 weeks’ gestationwho 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 vaginalbleeding.
A nurse is assessing a newborn and notes an axillarytemperature of 96.9°F (36°C).
Which of the following actions should the nurse perform?
Assess the newborn's blood glucose level
Infants who become cold attempt to generate heatthrough 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 temperaturefrom 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 linensand the vent.
,A nurse is caring for a client who is in preterm laborand 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 sulfateinfusion 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 ofheparin, not magnesium
sulfate.
B. Naloxone is an opioid reversal agent. It does notreverse 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 phytoestrogensexert a therapeutic effect on
engorged breasts.
Leaves should be replaced when they becomewilted.
,Incorrect Answers::
A. The client should be instructed to wear a tight- fitting bra or breast binders to
alleviate engorgementand 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 incarbohydrates when you
wake up."
The nurse should instruct the client to eat foods thatare 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 andvomiting.
B. The nurse should instruct the client to avoidbrushing her teeth
immediately after eating to decrease vomiting.
C. The nurse should instruct the client to eat saltyand 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? - Correct
Answer:
D.
"A progestin-only pill or injection is available for usewhile you are breastfeeding."
Progestin-only injections, implants, and birth controlpills are acceptable options for
clients who are breastfeeding, although some experts recommend waiting until 6 weeks
postpartum to initiate the medication.
Incorrect Answers::
A. Breastfeeding can inhibit ovulation or prolongmenstruation; however, it is
, not a reliable and effective means of birth control. The client mayexperience an
unplanned pregnancy if she waitsuntil her periods resume before considering
birthcontrol options.
B. Estrogen-containing birth control pills, implants, patches, and vaginal rings are not
recommended forclients who are breastfeeding due to the risk of inhibiting breast
milk production and supply.
C. Condoms and other non-hormonal birth controlmethods are appropriate for
clients who are breastfeeding; however, there are other methodsthat are also
appropriate.
A nurse is assessing a client who is receiving morphine via a patient-controlled
analgesia (PCA)pump following a cesarean birth. Which of the following findings
should the nurse report to the provider? - Correct Answer:
D.
Urine output 20 mL/hr
Opioid analgesics such as morphine can cause urinary retention. The client should have
a urinary output of at least 30 mL/hr. The nurse should reportthis finding to the
provider.
Incorrect Answers::
A. Opioid analgesics can cause respiratory depression. However, this respiratory
rate is withinthe expected reference range.
B. This temperature is within the expected referencerange.
C. Dizziness is a common adverse effect of receivingopioid analgesics. The nurse
should instruct the client to sit on the side of the bed before getting up,assist the client
with ambulation, and implement general safety measures. However, it is not necessary
to report this finding to the provider.
A nurse in a clinic is providing teaching to a client who is at 37 weeks of gestation and
is scheduled foran external cephalic version. Which of the following statements should
the nurse make? - Correct Answer:
B."You will receive a medication to relax your uterusprior to the procedure."
A client who is scheduled to undergo an external cephalic version often receives a
tocolytic prior to the procedure to allow the uterus to relax. A relaxeduterus allows
an easier version by the provider.
