Nokea
A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first?
- A. Give two breaths.
- B. Discontinue medications.
- C. Call a code.
- D. Check carotid pulse.
Correct Answer: A
Rationale: Immediate ventilation is critical.
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A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O− (negative), the baby's type is A+ (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate?
- A. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection.
- B. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital.
- C. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM.
- D. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.
Correct Answer: B
Rationale: RhoGAM is necessary to prevent sensitization.
The nurse is assessing a neonate in the newborn nursery. Which of the following findings in a newborn should be reported to the neonatologist?
- A. The eyes cross and uncross when they are open.
- B. The ears are positioned in alignment with the inner and outer canthus of the eyes.
- C. Axillae and femoral folds of the baby are covered with a white cheesy substance.
- D. The nostrils flare whenever the baby inhales.
Correct Answer: D
Rationale: Nostril flaring indicates respiratory distress.
A breastfeeding woman calls the pediatric nurse with the following complaint:"I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?" Which of the following replies by the nurse is appropriate at this time?
- A. Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes.
- B. Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula.
- C. The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula.
- D. In addition to giving the baby formula, you should wear a surgical face mask when you are around him.
Correct Answer: C
Rationale: Breastfeeding provides antibodies to protect the baby.
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?Select one that doesn't apply
- A. Purple-colored patches on the buttocks and torso.
- B. Bilateral whitish discharge from the breasts.
- C. Bloody discharge from the vagina.
- D. Sharply demarcated dark red area on the face.
Correct Answer: D
Rationale: Transient phenomena such as mongolian spots, witch's milk, and pseudo-menstruation are normal in newborns.
The nurse is going to assist the mother with the first breastfeeding experience. Which of the following actions should the nurse perform first?
- A. Compare mother's and baby's identification bracelets.
- B. Help the mother into a comfortable position.
- C. Teach the mother about a proper breast latch.
- D. Tickle the baby's lips with the mother's nipple.
Correct Answer: A
Rationale: Identity verification ensures correct pairing.