The nurse is evaluating the effectiveness of phototherapy on a newborn. Which evaluation indicates a therapeutic response to phototherapy?
1. The newborn maintains a normal temperature.
2. Bilirubin level of 14 mg/dl
3. Decreased reflexes
4. Skin blanching yellow
1
Rationale 1: Maintenance of temperature is an important aspect of phototherapy because the newborn is naked except for a diaper during phototherapy.
Rationale 2: Bilirubin levels of 6 mg/dl or less would be considered therapeutic.
Rationale 3: Reflexes during phototherapy should be normal, not decreased.
Rationale 4: Yellowing in the skin should disappear with effective phototherapy.
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Order for the PCA: Morphine sulfate 30 mg/30 mL Maximum dose: 28 mg in 4 hours Continuous dose: 1 mg/hr PCA dose: 1 mg Lockout: q10min The client has received a total of 14 mg in 4 hours. How many milligrams of the total dose are from the continuous dose?
a. 28 b. 10 c. 4 d. 14
A community health nurse is assigned to work in a different area of the city. Which of the following assessment techniques would she likely use to develop an overview of the community? Choose all that apply
1) Windshield survey 2) Review of demographic data 3) Physical assessment of a sample of the inhabitants 4) Review of the records of area providers
What is the priority nursing goal for a 14-year-old with Graves' disease?
a. Relieving constipation b. Allowing the adolescent to make decisions about whether or not to take medication c. Verbalizing the importance of adherence to the medication regimen d. Developing alternative educational goals
A client at 40 weeks' gestation is to undergo stripping of the membranes. The nurse provides the client with information about the procedure
Which information is accurate? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Intravenous administration of oxytocin will be used to initiate contractions. 2. The physician/CNM will insert a gloved finger into the cervical os and rotate the finger 360 degrees. 3. Stripping of the membranes will not cause discomfort, and is usually effective. 4. Labor should begin within 24-48 hours after the procedure. 5. Uterine contractions, cramping, and a bloody discharge can occur after the procedure.