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Questions 163

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Question 1 of 5

Which observation in the newborn of a diabetic mother would require immediate nursing intervention?

Correct Answer: C

Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, requiring immediate intervention. Crying, wakefulness, and yawning are normal behaviors, so A, B, and D are incorrect.

Question 2 of 5

A client indicates to the nurse a desire to become pregnant. The client drinks 1-2 glasses of wine on weekends. BMI is 32 kg/m². Which teachings should the nurse reinforce as part of proper preconception health care for this client? Select all that apply.

Correct Answer: A,B,D,E

Rationale:
To optimize preconception health: Avoid undercooked meat to prevent toxoplasmosis; limit alcohol to minimal or none to avoid fetal alcohol syndrome; rubella vaccine prevents congenital rubella syndrome; and folic acid reduces neural tube defects. A BMI of 32 is obese and should be reduced for healthier pregnancy outcomes.

Question 3 of 5

The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?

Correct Answer: B

Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.

Question 4 of 5

The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?

Correct Answer: B

Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.

Question 5 of 5

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?

Correct Answer: B

Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.

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