Nokea
A nurse is planning care for a client who is pregnant and has HIV.
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin-to-skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin-to-skin contact. This is because bathing the newborn before skin-to-skin contact helps reduce the risk of HIV transmission from mother to baby. HIV can be present in maternal blood and other fluids, and washing the newborn can decrease the viral load on the baby's skin. Initiating skin-to-skin contact without bathing first may increase the risk of transmission.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to baby. Choice C is incorrect as stopping antiretroviral medication can be harmful to both the mother and the baby's health. Choice D is incorrect as pneumococcal immunization is not recommended within 4 hours following birth and is not directly related to HIV transmission prevention.
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A nurse is assisting with an amniotomy on a client who is in labor. Which of the following situations should the nurse take?
- A. Place the client in the left lateral position
- B. Ensure that the fetal head is engaged
- C. Give the provider clean gloves during the procedure
- D. Check the clients temperature every 4 hours after the procedure
Correct Answer: B
Rationale: The correct answer is B: Ensure that the fetal head is engaged. This is crucial before performing an amniotomy to prevent umbilical cord prolapse. If the fetal head is not engaged, there is a risk of cord compression. Placing the client in the left lateral position (choice A) is not directly related to the amniotomy procedure. Giving the provider clean gloves (choice C) is important for infection control but not specifically related to ensuring fetal head engagement. Checking the client's temperature (choice D) is important for monitoring but not a priority before an amniotomy.
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn’s visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: The correct answer is D: Swaddle the newborn in a flexed position. This intervention helps provide comfort and security to the newborn, which can help reduce symptoms of neonatal abstinence syndrome. Swaddling in a flexed position mimics the womb environment, promoting relaxation and reducing irritability.
A: Increasing visual stimulation can overwhelm the newborn and exacerbate symptoms.
B: Weighing the newborn every other day is not directly related to managing neonatal abstinence syndrome.
C: Discouraging parental interaction can hinder bonding and support, which are crucial for the newborn's well-being.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing any procedure that involves contact with bodily fluids or potentially infectious material, such as blood or bodily secretions. Umbilical cord care may involve cleaning the area, which can have potential exposure to bodily fluids. The other choices (A, B, C) do not involve direct contact with bodily fluids or infectious material, so gloves are not necessary for those procedures. It is important to maintain infection control practices to prevent the spread of infections in the healthcare setting.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lamp. Which of the following actions should the nurse include in the plan?
- A. Apply a thin layer of lotion to the newborn skin every 8 hrs.
- B. Give the newborn 1oz of glucose water every 4 hrs
- C. Ensure the newborn eyes are closed beneath the shield.
- D. Dress the newborn in a thin layer of clothing during therapy
Correct Answer: C
Rationale: Rationale: Choice C is correct because ensuring the newborn's eyes are closed beneath the shield during phototherapy prevents potential eye damage from the bright light. Closing the eyes protects the delicate eye tissues from exposure to the intense light. This action is crucial in preventing eye injury and promoting the safety and well-being of the newborn.
Incorrect Choices:
A: Applying lotion to the skin can intensify the effects of the light and should be avoided.
B: Giving glucose water is unnecessary and not related to phototherapy.
D: Dressing the newborn in clothing can interfere with the effectiveness of the light therapy.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose level every hr. Neonatal abstinence syndrome can lead to hypoglycemia in infants. Monitoring blood glucose levels every hour allows for early detection and intervention. Providing a stimulating environment (A) can worsen symptoms. Initiating seizure precautions (C) is not necessary unless seizures are present. Placing the infant on his back with legs extended (D) does not address the specific issue of neonatal abstinence syndrome.