A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?

Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit.

Notify child protective services of the client’s illicit drug use and probable child endangerment.

Refer the client to an outpatient alcohol abuse program for disulfiram therapy.

Answer and Explanation

The Correct Answer is A

The correct answer is A. Praise the client for her actions and offer to discuss ways to decrease consumption even more.

Why? During pregnancy, any amount of alcohol poses a risk to the developing fetus, but abruptly shaming or forcing action may not be effective. The best approach is motivational interviewing, which involves acknowledging the client's reduction while encouraging further progress. A supportive conversation can help guide the client toward complete cessation of alcohol use.

Here’s why the other options are incorrect:

B. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit – While alcohol cessation is the goal, forcing the client without a supportive approach can lead to resistance. Routine blood alcohol testing is not standard unless substance dependence is suspected.
C. Notify child protective services of the client’s illicit drug use and probable child endangerment – Alcohol is not classified as an illicit drug, and reporting at this stage would be premature unless clear evidence of abuse or harm to the fetus exists.
D. Refer the client to an outpatient alcohol abuse program for disulfiram therapy – Disulfiram (Antabuse) is not recommended in pregnancy, as it may cause adverse effects. Instead, behavioral counseling and support groups are preferred interventions.

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Correct Answer is B

Explanation

Choice A rationale
While it is true that the ointment can help prevent certain types of infections, it is not specifically intended to prevent herpes infection. Herpes is a viral infection, and the ointment is an antibiotic, which is used to prevent bacterial infections.
Choice B rationale
The primary purpose of eye ointment is to protect newborns from serious eye infections caused by common bacteria. Mothers who have a sexually transmitted infection (STI) can pass it to their newborns during childbirth, putting them at risk for an eye infection known as ophthalmia neonatorum (ON)3.
Choice C rationale
The ointment does not serve to clear the infant’s vision. It is applied to the eyes to prevent bacterial infections, not to improve or alter the infant’s vision.
Choice D rationale
The ointment is not used to dilate the pupil to visualize the red reflex. The red reflex is a reflection from the lining of the eye that is often observed when looking at the pupil, but this is not related to the application of the ointment.

A. Flaring of the nares. B. Bilateral bronchial breath sounds. C. Diaphragmatic respirations. D. Resting respiratory rate of 35 breaths/minute. E. Resting respiratory rate of 35 breaths/minute.

Correct Answer is A

Explanation

Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.

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A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes. He asks the nurse about the purpose of the ointment. What would be the correct response from the nurse regarding the purpose of the ointment?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime.
What action should the nurse take?