Nokea
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.
You may also like to solve these questions
The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
- A. A client with peripheral vascular disease and an ulceration of the lower leg.
- B. A pre-operative client awaiting adrenalectomy with a history of asthma
- C. An elderly client with hypertension and self-reported non-compliance
- D. A new admission with a history of transient ischemic attacks and dizziness
Correct Answer: A
Rationale: This client is stable with no risk of instability as compared to the other clients. The client has a chronic condition and needs supportive care, which is appropriate for a UAP.
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
The licensed practical nurse is assisting the RN with preparation for administering a transfusion of whole blood. Which action by the nurse predisposes the client to the development of hyperkalemia?
- A. Allowing the blood to warm to room temperature
- B. Administering blood that is 24 hours old
- C. Administering blood with an 18-gauge needle
- D. Filling the drip chamber below the level of the filter
Correct Answer: A
Rationale: Allowing blood to warm to room temperature can cause red blood cells to hemolyze, releasing potassium and increasing the risk of hyperkalemia.
The nurse is caring for a client with a history of chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high for epoetin alfa therapy, increasing the risk of hypertension and thrombosis, requiring dose adjustment. Options B, C, and D are expected: potassium 4.5 mEq/L and calcium 9.0 mg/dL are normal, and creatinine 3.0 mg/dL is consistent with chronic kidney disease.
The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
- A. Heart rate of 128
- B. Respiratory rate of 72
- C. Hematocrit of 50%
- D. Blood glucose of 60 mg/100 mL
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.