The nurse is caring for a primigravida client who delivered vaginally 48-hours ago.The client's laboratory results are: hemoglobin 12 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus negative. Which prescription should the nurse prepare to administer?

Blood transfusion.

Rubella vaccination.

Penicillin G potassium.

Hepatitis B immunoglobulin.

Answer and Explanation

The Correct Answer is B

Choice A rationale

The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.

Choice B rationale

Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.

Choice C rationale

Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.

Choice D rationale

Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .

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Correct Answer is B

Explanation

Choice A rationale

Rooting is a reflex that helps a baby find and latch onto the breast or bottle for feeding. While the rooting reflex may diminish as the baby grows, it is not the primary indicator for introducing solid foods. Other developmental milestones are more relevant for this transition.

Choice B rationale

When a baby starts opening their mouth in response to the sight or smell of food, it indicates a readiness to try solid foods. This behavior shows that the baby is interested in and capable of learning to eat from a spoon, which is a key step in the introduction of solids.

Choice C rationale

Awakening once for nighttime feedings is common for infants and does not necessarily indicate readiness for solid foods. Nighttime awakenings can occur for various reasons, including hunger, but other developmental signs should be considered for introducing solids.

Choice D rationale

Giving up a bottle for a cup is a milestone that typically occurs later in infancy or toddlerhood. It is not directly related to the introduction of solid foods, which generally begins around 4 to 6 months of age based on the child's developmental readiness and interest in food.

A. Instill benzocaine otic drops regularly. B. Schedule a visit for the pneumococcal vaccine. C. Give the infant the full course of antibiotics. D. Avoid any smoking inside the house.

Correct Answer is A

Explanation

Choice A rationale

Benzocaine otic drops are used for pain relief and do not address the root cause of infections. Regular use without medical advice can lead to masking of symptoms and possibly delay appropriate treatment. The focus should be on preventing infections through other methods like vaccinations and avoiding irritants.

Choice B rationale

Scheduling a visit for the pneumococcal vaccine is appropriate as it can help protect against Streptococcus pneumoniae, a common cause of otitis media. Vaccinations are a preventive measure to reduce the frequency and severity of infections in infants and children.

Choice C rationale

Giving the infant the full course of antibiotics is crucial in treating and preventing recurrent infections. Incomplete antibiotic courses can lead to bacterial resistance and recurrence of infections. Caregivers must be educated on the importance of adhering to the prescribed treatment plan.

Choice D rationale

Avoiding smoking inside the house is essential as secondhand smoke is a significant risk factor for otitis media. Smoke can irritate the respiratory system and Eustachian tubes, making infants more susceptible to infections. Caregivers should be advised to maintain a smoke-free environment to protect the child's health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a 4-month-old baby girl asks the nurse when she should introduce solid foods to her infant.The mother states, "My mother says I should put rice cereal in the baby's bottle now.”. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

Correct Answer is B

Explanation

The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?

Correct Answer is A

Explanation

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?

The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for a client with preterm labor. The IV bag contains "Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.”. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "isoniazid Oral Solution, USP 50 mg per 5 mL.”. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.

A client who is 38 weeks pregnant is concerned her baby might get a communicable disease before any immunizations are given. Which physiological mechanism should the nurse use when responding to the mother's concerns?

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?