A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

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

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

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

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

Answer and Explanation

The Correct Answer is B

Choice A rationale

Notifying child protective services without further assessment may cause unnecessary distress and legal complications. The client's current alcohol use reduction efforts should be considered, and other interventions can be explored first.

Choice B rationale

Praising the client for reducing alcohol intake encourages positive behavior. Providing support and discussing ways to further decrease consumption promotes a collaborative approach to reducing alcohol exposure during pregnancy.

Choice C rationale

Disulfiram therapy is not suitable for pregnant clients due to potential risks. Instead, referral to an outpatient alcohol abuse program for counseling and support is more appropriate and safer for both mother and fetus.

Choice D rationale

Insisting on complete alcohol cessation without providing support may result in non-compliance. Drawing blood alcohol levels at each visit may cause anxiety and is not a practical approach for monitoring alcohol use in pregnancy.

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Correct Answer is B

Explanation

Choice A rationale

Shallow and irregular respirations are normal for newborns and do not typically indicate respiratory distress. Regular assessment is necessary to determine if there is an underlying issue.

Choice B rationale

Flaring of the nares is a sign of increased effort to breathe and is an indication of respiratory distress in newborns. This symptom requires immediate attention to address potential underlying conditions.

Choice C rationale

Abdominal breathing with synchronous chest movement is normal in newborns due to their diaphragmatic breathing pattern. It does not indicate respiratory distress unless other symptoms are present.

Choice D rationale

A respiratory rate of 50 breaths per minute is within the normal range for newborns (30-60 breaths per minute). This does not indicate respiratory distress unless accompanied by other abnormal signs.

A. Request placement of the epidural. B. Give a bolus of intravenous fluids. C. Decrease the oxytocin infusion rate. D. Determine current cervical dilation.

Correct Answer is D

Explanation

Choice A rationale

Epidural placement requires assessing the current cervical dilation and fetal station. Without this information, premature epidural placement can impede labor progress or mask signs of complications.

Choice B rationale

A bolus of intravenous fluids is necessary before epidural anesthesia to prevent hypotension. However, assessing cervical dilation first ensures that it is appropriate to proceed with pain management.

Choice C rationale

Decreasing the oxytocin infusion rate is not the initial priority. The current cervical dilation and effacement need to be assessed to determine the appropriate management of labor and pain control.

Choice D rationale

Determining current cervical dilation is the first action to evaluate labor progress and make informed decisions regarding pain management and epidural placement, ensuring safe and effective care.

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A client at 9 weeks gestation tells the nurse that while she has cut down, she still has at least one alcoholic drink every evening before bedtime. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a newborn assessment. Which symptom, if present in a newborn, would indicate respiratory distress?

Correct Answer is B

Explanation

A client whose labor is being augmented with an oxytocin infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a -2 station. Which action should the nurse implement first?

Correct Answer is D

Explanation

A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?

Following an amniocentesis, a client verbalizes several concerns. Which reported finding indicates to the nurse that the client is experiencing a complication from the amniocentesis?

The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)

The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?

After two miscarriages, a client is instructed to increase her daily intake of foods that includes folic acid. The client does not like green leafy vegetables and states she is allergic to soy. Which food should the nurse suggest that the client eat to obtain folic acid?

A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?

The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?