Nokea
A 23 years old primigravida comes in labour room for induction of labour. Cervix is closed and 3 cm long. Which of the following medicine will be given to her for cervical ripening?
- A. Methergin.
- B. Salbutamol.
- C. Prostaglandin E2.
- D. Paracetamol.
- E. Methyldopa.
Correct Answer: C
Rationale: Prostaglandin E2 is used for cervical ripening in induction of labor as it softens and dilates the cervix. Other medications are not indicated for this purpose.
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The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
The nurse completed discharge education to the Native American parents of a 48-hour-old,full-term infant. The nurse concludes that the mother needs additional teaching about jaundice when she makes which statement?
- A. “I know keeping my baby warm will help to decrease jaundice.”
- B. “I know the jaundice should start to decrease after about 3 days.”
- C. “The bilirubin causing the jaundice is eliminated in my baby’s stools.”
- D. “Feeding my baby frequently will help to decrease the jaundice.”
Correct Answer: B
Rationale: In Native American infants jaundice persists longer than in Caucasians with peak bilirubin at 3–5 days. Keeping warm frequent feeding and stool elimination of bilirubin are correct.
The nurse finds documentation in the 4-hour-old newborn’s medical record that states,“Clamping of the umbilical cord was delayed until cord pulsations ceased.” When assessing and collecting additional information about the newborn,what effect should the nurse find as a result of the delayed cord clamping?
- A. More rapid expulsion of meconium by the newborn
- B. Increased level of newborn alertness after birth
- C. An increase in the newborn’s initial temperature
- D. An increase in the newborn’s hemoglobin and hematocrit
Correct Answer: D
Rationale: Newborn Hgb and Hct values will be higher when placental transfusion accomplished through delayed cord clamping occurs at birth. Blood volume increases by up to 50% with delayed cord clamping. Meconium passage alertness and temperature are not affected by delayed clamping.
Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.