1. nurse is planning care for a requires phototherapy for hyperbilirubinemia.
Which of the following actions should the nurse include inthe plan of care:
En- sure 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.
2. 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?: "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
1/
,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.
3. 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?: 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.
4. 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?: Check the cervix prior to analgesic administration. - Prior
to administering an analgesic during active labor, the nurse must know
2/
, 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.
5. 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?: Group B
streptococcus Beta-hemolytic (GBS) - The nurse should obtain a
vaginal/anal group B streptococ- cus 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.
6. 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?:
Respira- tory depression - Magnesium sulfate can cause respiratory and
neuromuscular depression in the newborn. The nurse should monitor
the newborn for clinical manifestations of respiratory depression.
3/
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