The perinatal nurse notes the following data concerning a new mother/infant couplet who are being admitted: the mother experienced an extended second stage of labor and a vacuum-assisted birth; the infant has a cephalhematoma; the maternal blood type
is A+ and the infant's blood type is O+; and the first breastfeeding was delayed for 3 hours. Which risk factors are present for the development of neonatal hyperbilirubinemia?
Select all answers that apply.
A) Birth trauma
B) Inadequate output
C) ABO incompatibility
D) Inadequate intake
A, B, D
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A teenage girl has been admitted to a residential treatment facility because of anorexia nervosa. Her parents agree to tell people that she is attending a boarding school for the remainder of the semester. What is this agreement an example of?
A) Pathology B) Interdependency C) A family boundary D) Carrying out family roles
Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug include:
a. Avoiding use of sunscreen agents. b. Using cosmetics with lanolin and petrolatum. c. Explaining that medication should not be applied until at least 20 to 30 minutes after washing. d. Explaining that erythema and peeling are indications of toxicity.
When educating a patient about glargine (Lantus), the nurse should explain that this medication
A) has a rapid onset and peaks in about 5 minutes after injection, so he will need to eat food immediately after injection. B) will have a peak effect within 30 minutes, so it can be taken after a meal. C) is a combination with short-acting and intermediate-acting insulin, so it is safe to take anytime throughout the day. D) has a prolonged absorption rate and provides a relatively constant concentration for 12 to 24 hours.
The nurse is caring for an older patient. What should the nurse realize is an expected age-related change in this patient's musculoskeletal system?
1. difficulty with dexterity after age 50 2. vertebrae lengthening and thinning, which leads to increased bone production 3. decreased bone mass and calcium absorption, which increase risk for fractures 4. pain when ambulating due to increased bone mass and minerals