Accurate Answers 2025-2026 Updated
nurse is planning care for a requires phototherapy for hyperbilirubinemia. Which of the following
actions should the nurse include in the plan of care - Answer Ensure the newborns eyes are closed
before applying the eye shield - Overexposure to the lights during treatment can cause damage to the
newborn's corneas. Therefore, the nurse should gently close the newborn's eyes prior to applying the
eye shield.
A nurse is caring for a client at 34 weeks gestation and has a prescription for terbutaline for preterm
labor. Which of the following statements by the patient is the priority? - Answer "My heart feels as if it is
racing." - the nurse should assess the client's heart rate. The primary action of terbutaline is to cause
bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is
greater than 130/min, the terbutaline needs to be held until the provider is notified. The nurse might
also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge
to identify which finding is the most urgent.
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following
situations should the nurse administer Rh(D) Immune Globulin? - Answer at 28 weeks of gestation - The
nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood
at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor,
which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.
A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the
following actions should the nurse include in the plan of care? - Answer Check the cervix prior to
analgesic administration. - Prior to administering an analgesic during active labor, the nurse must know
how many centimeters the cervix is dilated. If administered too close to the time of delivery, the
analgesic could cause respiratory depression in the newborn.
A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following lab tests
should the nurse obtain? - Answer Group B Streptococcus Beta-hemolytic (GBS) - The nurse should
obtain a vaginal/anal group B streptococcus ß-hemolytic (GBS) culture at 35 to 37 weeks of gestation to
screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for
GBS.
, A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor.
Which of the following clinical manifestations is the newborn indicates toxicity due to the magnesium
sulfate therapy? - Answer Respiratory depression - Magnesium sulfate can cause respiratory and
neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical
manifestations of respiratory depression.
A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is
a complication from the epidural block? - Answer hypotension - Maternal hypotension is an adverse
effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of
epidural anesthesia in order to decrease the likelihood of this complication.
A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the
following instructions should the nurse provide to the client about the treatment plan? - Answer "You
and your partner need to take the medication and use a condom during intercourse until cultures are
negative." - Trichomonas vaginalis is the organism that causes the sexually transmitted infection
trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include
yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as
itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with
metronidazole. However, for the treatment to work, it is important to make sure both sexual partners
receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse
while being treated.
A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight.
The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the
following responses should the nurse make? - Answer A weight gain of 25 - 35 lbs is good - A weight gain
of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each
for the second and third trimester is recommended.
A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended
action of the med in relation to the CNS? - Answer Block effects of narcotics on the CNS- By blocking the
effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn
following delivery.
A nurse is discussing diaphragm use with a client. Which of the following statements by client indicates
an understanding of the teaching? - Answer I should replace my diaphragm every 2 years - The
diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to
intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2
years.