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When assessing a newborn with respiratory distress syndrome who received synthetic surfactant, which parameter should the nurse monitor to evaluate the newborn's condition?
- A. Oxygen saturation
- B. Body temperature
- C. Serum bilirubin
- D. Heart rate
Correct Answer: A
Rationale: The correct answer is A: Oxygen saturation. Monitoring oxygen saturation is crucial in evaluating the newborn's respiratory status post-surfactant administration. It helps assess the effectiveness of surfactant therapy in improving oxygenation. Body temperature and serum bilirubin are not directly related to assessing respiratory distress syndrome. Heart rate may be affected by various factors and may not provide specific information on respiratory status.
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When should a provider order a maternal serum alpha-fetoprotein (MSAFP) screening for pregnant clients?
- A. A client who has mitral valve prolapse
- B. A client who has been exposed to AIDS
- C. All pregnant clients
- D. A client who has a history of preterm labor
Correct Answer: C
Rationale: Rationale:
- MSAFP screening is recommended for all pregnant clients to assess risk of neural tube defects or chromosomal abnormalities.
- It is a standard prenatal test regardless of specific medical conditions.
- Options A, B, and D are not directly related to the indication for MSAFP screening in pregnancy.
A healthcare provider is assisting with the care of a newborn immediately following birth. Which of the following nursing interventions is the highest priority?
- A. Initiating breastfeeding
- B. Performing the initial bath
- C. Giving a vitamin K injection
- D. Covering the newborn's head with a cap
Correct Answer: D
Rationale: The correct answer is D: Covering the newborn's head with a cap. This is the highest priority as newborns are at risk for heat loss due to their large head surface area. By covering the newborn's head with a cap, heat loss can be minimized, helping to maintain the baby's body temperature. This is crucial for the newborn's overall well-being and to prevent complications such as hypothermia.
Initiating breastfeeding (A) is important for newborn nutrition but can be delayed slightly without immediate harm. Performing the initial bath (B) can also wait as it is not as urgent as maintaining the newborn's temperature. Giving a vitamin K injection (C) is important for blood clotting but can be done after ensuring the baby's temperature is stable.
A client is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown after childbirth. Which of the following conditions is associated with these manifestations?
- A. Postpartum fatigue
- B. Postpartum psychosis
- C. Letting-go phase
- D. Postpartum blues
Correct Answer: D
Rationale: The correct answer is D: Postpartum blues. This temporary condition occurs in the first few days after childbirth and is characterized by symptoms like tearfulness, insomnia, lack of appetite, and feeling letdown. Here's the rationale:
1. Postpartum blues are common and typically resolve within a few days to a week postpartum.
2. The symptoms mentioned align with the typical presentation of postpartum blues, which includes mood swings, irritability, and crying spells.
3. Postpartum fatigue (choice A) is a general symptom post-childbirth but does not specifically encompass the emotional and psychological symptoms described.
4. Postpartum psychosis (choice B) is a severe condition characterized by hallucinations, delusions, and disorganized thinking, which are not present in the client's presentation.
5. Letting-go phase (choice C) refers to the process of detachment from the pregnancy and accepting the reality of the newborn, but it does not encompass the specific symptoms described in
A client has postpartum psychosis. Which of the following actions is the nurse's priority?
- A. Reinforce the importance of taking antipsychotics as prescribed
- B. Ask the client if they have thoughts of harming themselves or their infant
- C. Monitor the infant for signs of failure to thrive
- D. Check the client's medical record for a history of bipolar disorder
Correct Answer: B
Rationale: The correct answer is B: Ask the client if they have thoughts of harming themselves or their infant. This is the priority because postpartum psychosis poses a risk of harm to the client and the infant. Assessing for suicidal or homicidal ideation is crucial to ensure safety. Choice A may be important but ensuring immediate safety takes precedence. Choice C is important but not the priority. Choice D may provide background information but does not address the immediate safety concern.
During an assessment, a healthcare provider observes small pearly white nodules on the roof of a newborn's mouth. This finding is a characteristic of which of the following conditions?
- A. Mongolian spots
- B. Milia spots
- C. Erythema toxicum
- D. Epstein's pearls
Correct Answer: D
Rationale: The correct answer is D: Epstein's pearls. These small pearly white nodules are commonly found on the roof of newborns' mouths and are considered a normal finding. They are formed from trapped epithelial cells during the development of the baby's mouth. They are harmless and typically resolve on their own without treatment.
A: Mongolian spots are bluish-black or bruise-like markings found on the skin, not in the mouth.
B: Milia spots are small, white, raised bumps on the skin, not found in the mouth.
C: Erythema toxicum is a common benign rash in newborns, not related to the mouth.
In summary, Epstein's pearls are the correct answer due to their specific location in the newborn's mouth, their appearance, and the fact that they are a normal finding in newborns. The other choices are incorrect as they describe different conditions not related to the oral cavity.