the nurse observes a mother giving her 11 month old ferrous sulfate iron drops followed by 2 ounces of orange juice what should the nurse do next
Logo

Nursing Elites

HESI RN

HESI Maternity Test Bank

1. The caregiver observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the caregiver do next?

Correct answer: D

Rationale: The high vitamin C content in orange juice aids in the absorption of iron. Providing positive feedback to the mother for administering the iron drops with orange juice is appropriate as it enhances iron absorption, benefiting the infant. Encouraging and acknowledging correct medication administration can help reinforce good practices and build confidence in the caregiver. Choices A, B, and C are incorrect because they do not align with the beneficial practice of administering iron drops with orange juice, which enhances iron absorption. Changing the method of administration based on incorrect assumptions or instructing to withhold feeding after giving iron drops is unnecessary and not evidence-based.

2. When assessing a client who is at 12-weeks gestation, the LPN/LVN recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

Correct answer: D

Rationale: The best time for the couple to attend childbirth preparation classes is around 30 weeks gestation, which is during the third trimester. Attending classes at this time allows the couple to learn essential information and skills as labor and delivery are approaching, maximizing the benefit of the classes. Option A is too early in the second trimester, and the couple might forget important details by the time labor approaches. Option B is also early in the second trimester, and attending later allows for better preparation. Option C is still in the second trimester, and waiting until the third trimester provides more practical knowledge closer to delivery.

3. Which intervention is most helpful in relieving postpartum uterine contractions or 'afterpains'?

Correct answer: A

Rationale: Lying prone with a pillow on the abdomen is the most helpful intervention in relieving postpartum uterine contractions or 'afterpains.' This position provides counter-pressure and support to the uterus, helping to alleviate discomfort and promote uterine involution. Choice B, using a breast pump, is not effective in relieving afterpains as it focuses on milk expression. Massaging the abdomen (Choice C) may help with discomfort but does not provide the same level of support as lying prone with a pillow. Giving oxytocic medications (Choice D) is not typically the first-line intervention for afterpains unless there are specific medical indications.

4. During the newborn admission assessment, the nurse palpates the newborn's scrotum and does not feel the testicles. Which assessment technique should the nurse perform next to verify the absence of testes?

Correct answer: C

Rationale: If the testes are not palpated in the scrotum, the next step is to check the inguinal canal for a retractile or undescended testis. This technique allows the nurse to determine if the testes are located within the inguinal canal rather than the scrotum. It is essential to assess for the presence of testes in the inguinal canal to ensure proper diagnosis and management of any potential issues related to testicular positioning.

5. The client is 30 weeks pregnant and experiencing preterm labor. Which medication should the nurse anticipate administering to promote fetal lung maturity?

Correct answer: A

Rationale: Betamethasone (Celestone) is the medication of choice to promote fetal lung maturity in cases of preterm labor. It helps accelerate surfactant production in the fetal lungs, reducing the risk of respiratory distress syndrome. Administering betamethasone to the mother can improve the baby's lung function and overall outcome if preterm birth occurs. Magnesium sulfate is commonly used to prevent seizures in preeclampsia or eclampsia. Terbutaline is a tocolytic agent used to suppress preterm labor contractions. Ampicillin is an antibiotic used for various bacterial infections but does not promote fetal lung maturity.

Similar Questions

A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28 weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The LPN/LVN plans to monitor for which primary side effect of terbutaline sulfate?
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The LPN/LVN knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as
Assessment findings of a 4-hour-old newborn include: axillary temperature of 96.8°F (35.8°C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonia, and weak cry. Based on these findings, which action should the nurse implement?
The LPN/LVN is providing discharge teaching for a client who is 24 hours postpartum. The nurse explains to the client that her vaginal discharge will change from red to pink and then to white. The client asks, 'What if I start having red bleeding after it changes?' What should the nurse instruct the client to do?
A client at 18-weeks gestation was informed this morning that she has an elevated alpha-fetoprotein (AFP) level. After the healthcare provider leaves the room, the client asks what she should do next. What information should the nurse provide?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses