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A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
- A. Bulging Fontanels
- B. Nasal Flaring
- C. Length from head to heel of 40 cm (15.7 in)
- D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Correct Answer: D
Rationale: The correct answer is D because a chest circumference smaller than the head circumference is a normal finding in a newborn due to the larger head size compared to the chest. This is known as head sparing and is essential for brain development. Bulging fontanels (choice A) are abnormal and may indicate increased intracranial pressure. Nasal flaring (choice B) is a sign of respiratory distress. A length of 40 cm (choice C) is within the average range but not a specific expectation upon admission. Therefore, choice D is the most appropriate expectation for a newborn assessment.
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A nurse is caring for a client who has maternal hypotension following the placement of an epidural. Which of the following actions should the nurse take?
- A. Give terbutaline Subq
- B. Position the client in a knee chest position
- C. Apply oxygen via nonrebreather
- D. Administer a bolus of lactated ringer
Correct Answer: D
Rationale: The correct answer is D: Administer a bolus of lactated Ringer. Maternal hypotension following epidural placement indicates hypovolemia or vasodilation. Providing a bolus of lactated Ringer helps increase intravascular volume, improving blood pressure. Terbutaline Subq (A) is not indicated for hypotension. Positioning the client in a knee-chest position (B) is not appropriate for maternal hypotension. Applying oxygen via non-rebreather (C) may not address the underlying cause of hypotension.
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Transient circumoral cyanosis
- B. Single palmar creases
- C. Subconjunctival hemorrhage
- D. Rust-stained urine
Correct Answer: B
Rationale: The correct answer is B: Single palmar creases. This finding may indicate the presence of Down syndrome or other genetic disorders. The presence of single palmar creases warrants further evaluation by the provider to rule out any underlying conditions. Transient circumoral cyanosis, subconjunctival hemorrhage, and rust-stained urine are common and typically benign findings in newborns that do not require immediate reporting.
A nurse on postpartum unit caring for four clients. Which of the following clients should receive Rh, (D) Immune globulin to prevent Rh- is immunization?
- A. An Rh-negative mother who has an Rh- positive infant
- B. An Rh –positive mother who has an Rh- negative infant
- C. An Rh-positive mother who has an Rh- positive infant
- D. An Rh- negative mother who has an Rh- negative infant
Correct Answer: A
Rationale: The correct answer is A: An Rh-negative mother who has an Rh-positive infant. This mother is at risk for developing Rh isoimmunization, a condition where her immune system attacks the Rh-positive red blood cells of her infant, potentially causing harm in future pregnancies. Rh(D) Immune globulin is given to prevent this by blocking the mother's immune response to the Rh-positive cells of the infant. The other choices do not require Rh(D) Immune globulin because they do not involve the risk of Rh isoimmunization. Choice B involves an Rh-positive mother who is not at risk of isoimmunization. Choice C involves an Rh-positive mother with an Rh-positive infant, so there is no incompatibility. Choice D involves an Rh-negative mother with an Rh-negative infant, so there is no risk of isoimmunization.
A nurse is reviewing the laboratory results for a newborn 12 hours old. Which of the following is an expected findings.
- A. Glucose 40mg/dl
- B. WBC 6000
- C. Hemoglobin 12
- D. Platelets 80000
Correct Answer: A
Rationale: The correct answer is A: Glucose 40mg/dl. In newborns, normal glucose levels range from 40-60mg/dl. This level is expected to be lower in the immediate postnatal period due to the transition from placental to independent glucose regulation. WBC count of 6000 is within normal range. Hemoglobin at 12 is normal for a newborn. Platelets of 80000 are low and could indicate a potential issue, such as thrombocytopenia, which would require further investigation.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I should position my baby’s car seat at a 45-degree angle in the car.”
- B. “I should place the car seat rear facing until my baby is 12 months old.”
- C. “I should place the harness snugly in a slot above my baby’s shoulders.”
- D. “I should position the retainer clip at the top of my baby’s abdomen.”
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.