A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

"Go to the emergency room and your provider will meet you the

"Come to the office and we will check things out."

"What else have you been eating?"

"This is expected because of the way iron is broken down during digestion."

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Going to the emergency room for black stools without abdominal pain or cramping is not warranted in this situation.
Choice B rationale:
Having the client come to the office to check things out may not be necessary since black stools can be an expected side effect of iron supplements and do not necessarily indicate a problem.
Choice C rationale:
Asking about the client's diet is a valid question, but the black stools are likely due to iron supplements' effects and not related to dietary choices.
Choice D rationale:
Black stools are a known side effect of iron supplements. When iron is broken down during digestion, it can cause the stools to appear black or dark. As the client has no other concerning symptoms like abdominal pain or cramping, this response by the nurse reassures the client that the finding is expected and not a cause for alarm.

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Correct Answer is B

Explanation

Choice A rationale:

Administering the hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen is not the appropriate treatment for a newborn whose mother is positive for the hepatitis B surface antigen. Immediate intervention is required to prevent transmission.
Choice B rationale:

The newborn of a mother who is positive for the hepatitis B surface antigen should receive hepatitis B immune globulin (HBIG) and the hepatitis B vaccine within 12 hours of birth. HBIG provides passive immunity to the baby while the vaccine stimulates active immunity.
Choice C rationale:

Administering hepatitis B immune globulin for 1 week followed by the hepatitis B vaccine monthly for 6 months is not the correct treatment plan. Immediate intervention is necessary to prevent transmission to the newborn.
Choice D rationale:

Administering the hepatitis B vaccine at 24 hours followed by hepatitis B immune globulin every 12 hours for 3 days is not the appropriate treatment. Hepatitis B immune globulin should be given within 12 hours of birth, not over several days.

A. "There's absolutely nothing for you to worry about. Newborns often breathe like this." B. "I'll sit here while you feed him and we'll check out his breathing." C. "You are going to be a very good, responsible mother to this baby." D. "All new mothers feel a bit anxious about things like this."

Correct Answer is B

Explanation

Choice A rationale: While it's true that newborns can have irregular breathing patterns, this response may come across as dismissive and not addressing the client's concerns.
Choice B rationale: The nurse should respond by actively listening to the client's concerns and offering to assess the newborn's breathing while they are feeding. Newborns can have irregular breathing patterns, including periods of rapid breathing (tachypnea) and pauses in breathing (periodic breathing). These patterns are generally normal and related to the baby's immature respiratory system adjusting to life outside the womb.
Choice C rationale: This response does not address the client's concern about the baby's breathing and instead focuses on the client's potential as a mother.
Choice D rationale: This response may minimize the client's concerns and does not address the baby's breathing issue. It's essential to acknowledge and assess the newborn's breathing pattern to ensure it is within the normal range.

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A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the infant receive?

Correct Answer is B

Explanation

A nurse is caring for a client who is 1 day postpartum. The client tells the nurse, "The baby has been breathing funny, fast and slow, off and on." Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is at 23 weeks of gestation and will return to the facility the following week for an amniocentesis. Which of the following instructions should the nurse include?

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A nurse is performing Leopold maneuvers on a client who is in labor and determines the fetus is in an RSA position. Which of the following fetal presentations should the nurse document in the client's medical record?

A nurse is reinforcing teaching about strategies to calm a newborn with a client who is postpartum. Which of the following suggestions should the nurse make? (Select all that apply.)

A client who is 7 days postpartum calls the provider's office and reports pain, swelling, and redness of her left calf. Besides the client seeing the provider, which of the following interventions should the nurse suggest?

A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

A nurse is caring for a newborn. How many blood vessels should the nurse expect to observe in the newborn's umbilical cord?