A nurse is teaching a client who has bradycardia about how to prevent vagal stimulation. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

"Attempt to gag”

"Take an antiemetic when feeling nauseated."

"Apply firm pressure to the eyes."

"Eat a high-fiber diet to keep stools soft."

"Bear down to slow the pulse rate."

Answer and Explanation

Correct Answer : B,D

A. "Attempt to gag": Gagging stimulates the vagus nerve and can worsen bradycardia. Clients should be instructed to avoid actions that trigger the gag reflex, so this instruction is not recommended.

B. "Take an antiemetic when feeling nauseated.": Nausea and vomiting can increase vagal stimulation. Taking an antiemetic as prescribed helps prevent excessive vagal nerve activation, which can reduce the risk of further slowing the heart rate.

C. "Apply firm pressure to the eyes": Applying pressure to the eyes can stimulate the vagus nerve, potentially exacerbating bradycardia. Clients should avoid eye rubbing or pressure.

D. "Eat a high-fiber diet to keep stools soft": Straining during defecation stimulates the vagus nerve and can worsen bradycardia. A high-fiber diet promotes regular, soft stools and helps prevent straining, thereby reducing vagal stimulation.

E. "Bear down to slow the pulse rate": Bearing down (Valsalva maneuver) directly increases vagal stimulation, which can dangerously slow the heart rate in clients with bradycardia. This action should be avoided.

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Correct Answer is B

Explanation

A. "You will have a urine test for the herpes simplex virus": Routine prenatal screening does not include urine testing for herpes simplex virus. Testing for HSV is typically done based on symptoms or history, not as a standard prenatal test.

B. "You will have a rectovaginal culture to test for group B streptococcus.": Group B streptococcus screening is a standard prenatal test performed between 35 and 37 weeks of gestation using a rectovaginal swab. Identifying colonization allows for intrapartum antibiotic prophylaxis to prevent neonatal infection.

C. "You will have a urine test to check for toxoplasmosis": Routine urine testing does not screen for toxoplasmosis. Testing for toxoplasmosis is usually done via blood tests in women at high risk, not standard urine tests.

D. "You will undergo amniotic fluid sampling to test for cytomegalovirus.": Amniocentesis for cytomegalovirus is not part of routine prenatal care and is typically only performed if there is a known risk or suspected fetal infection. Standard prenatal tests focus on more common conditions.

A. Thrombocytopenia B. Hypothermia C. Maternal diabetes D. Prematurity E. Anemia

Correct Answer is ["B","C","D"]

Explanation

Rationale:

A. Thrombocytopenia: Low platelet count is not a recognized risk factor for neonatal hypoglycemia. While it may indicate other hematologic concerns, it does not directly affect the infant’s glucose regulation.

B. Hypothermia: Hypothermia increases metabolic demand and glucose consumption in newborns, making them more susceptible to hypoglycemia. Maintaining neutral thermal environment is crucial to reduce this risk.

C. Maternal diabetes: Infants of mothers with diabetes are at increased risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the high insulin levels can cause a rapid drop in blood glucose.

D. Prematurity: Premature infants have limited glycogen stores, immature liver function, and impaired gluconeogenesis, all of which increase the risk of hypoglycemia. Monitoring and early feeding are essential.

E. Anemia: While anemia can affect oxygen delivery, it is not a direct risk factor for hypoglycemia in the newborn. It may complicate overall neonatal status but does not independently cause low blood glucose.

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A nurse is teaching a client who has bradycardia about how to prevent vagal stimulation. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client about routine prenatal testing, which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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