QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) |ALREADY
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nurse is planning care for a requires phototherapy for hyperbilirubinemia. Which of the
following actions should the nurse include inthe plan of care -100%CORRECT VERIFAID 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? -100%CORRECT
VERIFAID 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? -100%CORRECT
VERIFAID 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 has clinical manifestations of an ectopic pregnancy. Which of
the following findings is a risk factor for an ectopic pregnancy? -100%CORRECT VERIFAID
ANSWER--pelvic inflammatory disease (PID) - An ectopic pregnancy occurs when the fertilized
, egg implants in tissue outside of the uterus and the placenta and fetus begin to develop there.
The most common site is within a fallopian tube, but ectopic pregnancies can occasionally occur
in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal
infection or tubal surgery. Therefore, PID places the client at risk for an ectopic pregnancy.
A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the
following instructions should the nurse provide the client? -100%CORRECT VERIFAID ANSWER--Eat
some crackers before rising from bed in the morning - Morning sickness is caused by the
buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before
rising in the morning tend to reduce the risk of nausea in clients who are pregnant.
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? -100%CORRECT VERIFAID 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? -100%CORRECT VERIFAID 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? -100%CORRECT VERIFAID 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? -100%CORRECT VERIFAID 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.