A newborn with a yellow abdomen and chest is being assessed. What should the nurse do?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Assess bilirubin level. Neonatal jaundice is a common condition in newborns due to the breakdown of fetal red blood cells and the immature liver's inability to effectively process bilirubin. Assessing the bilirubin level is crucial to determine the severity of jaundice and guide appropriate interventions. Option B) Administer phototherapy is a common treatment for neonatal jaundice, but it should not be the first step without assessing the bilirubin level first. Option C) Encouraging feeding to help reduce bilirubin levels is not the immediate action needed in this case. While breastfeeding can help with the elimination of bilirubin, it is not the primary intervention when jaundice is already present. Option D) Performing a bilirubin test every hour is excessive and not necessary. Monitoring bilirubin levels is important, but the frequency of testing should be based on the healthcare provider's assessment. Educationally, understanding the pathophysiology of neonatal jaundice, the importance of timely assessment, and appropriate interventions is crucial for nurses caring for newborns. This case highlights the significance of prioritizing assessments and interventions based on the clinical situation to provide safe and effective care for neonates.

Correct Answer: A

Rationale: When preparing to measure the fundal height of a pregnant client, it is crucial to have the client empty her bladder before the procedure. This is the correct action because a full bladder can impede accurate fundal height measurement by pushing the uterus upwards, leading to an incorrect assessment. Option B is incorrect because lying on the left side is not necessary for fundal height measurement. Option C, performing Leopold's maneuvers first, is also incorrect as these maneuvers are used to determine fetal position and presentation, not for fundal height measurement. Option D, giving the client cold juice to drink, is incorrect as it is not relevant to the fundal height measurement process. In an educational context, students must understand the importance of preparing the client appropriately for fundal height measurement to ensure accurate assessment of fetal growth and development. Emphasizing the significance of a standardized procedure, including bladder emptying, can help students develop the necessary skills for effective maternity care.

Correct Answer: D

Rationale: The correct answer to this question is D) Do you have a history of rheumatic fever? This is the most important question for the LPN/LVN to ask the client because the symptoms described - pedal edema, dyspnea, fatigue, and a moist cough - are indicative of cardiac issues, specifically heart failure. Rheumatic fever is a known risk factor for the development of rheumatic heart disease, which can lead to heart failure during pregnancy. Option A) Which symptom did you experience first? While understanding the progression of symptoms can provide some insight, it is not as crucial as identifying a potential underlying cardiac condition. Option B) Are you eating large amounts of salty foods? While dietary habits can contribute to edema and other symptoms, in this case, the symptoms presented are more likely related to a cardiac issue rather than dietary choices. Option C) Have you visited a foreign country recently? This question is not relevant to the symptoms described and does not address the immediate concern of cardiac involvement. In an educational context, it is essential for healthcare providers to be able to recognize and assess symptoms that may indicate serious conditions during pregnancy. Understanding the significance of a client's medical history and risk factors is crucial in providing appropriate care and interventions to ensure the well-being of both the mother and the baby.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A: 3+ deep tendon reflexes and hyperreflexia. These findings are indicative of an impending convulsion in a client with preeclampsia. Preeclampsia is characterized by hypertension and proteinuria after 20 weeks of gestation. As the condition progresses, it can lead to severe complications like eclampsia, which involves seizures or convulsions. Option B, periorbital edema, flashing lights, and aura, are signs of visual disturbances associated with preeclampsia but do not directly indicate an impending convulsion. Option C, epigastric pain in the third trimester, is a common symptom of preeclampsia but is not specifically linked to an impending convulsion. Option D, recent decreased urinary output, is a sign of kidney involvement in preeclampsia but does not directly predict an impending convulsion. Educationally, understanding the signs and symptoms of preeclampsia is crucial for nurses and healthcare providers caring for pregnant clients. Recognizing the warning signs of severe complications like impending convulsions allows for prompt intervention and management to ensure the safety of both the mother and the baby. Regular assessment and monitoring of clients with preeclampsia are essential to prevent adverse outcomes.

Correct Answer: C

Rationale: The correct answer is C. Epoetin alfa stimulates erythropoiesis, leading to an increase in red blood cell production and improving oxygen-carrying capacity. As the oxygenation status improves, there is a reduction in heart rate. Therefore, changes in apical heart rate from the 180s to the 140s indicate that the drug is effective.