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A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood incompatibility in the neonate is which complication or test result?
- A. Negative Coombs test
- B. Bleeding from the nose and ear
- C. Jaundice after the first 24 hours of life
- D. Jaundice within the first 24 hours of life
Correct Answer: D
Rationale: A neonate born to a mother with blood type AB and a father with blood type O is at risk for ABO blood incompatibility, particularly if the neonate is blood type A or B. The major sign of ABO blood incompatibility in the neonate is the development of jaundice within the first 24 hours of life. This occurs due to the mismatch in blood types between the mother and the neonate, leading to the destruction of the neonate's red blood cells. This destruction releases bilirubin, causing jaundice. It is important to note that unlike Rh incompatibility, ABO incompatibility usually does not lead to severe complications requiring treatment. A positive Coombs test result is not typically seen in ABO blood incompatibility.
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A nurse is assessing a preterm newborn. Which assessment findings are consistent with prematurity? (Select all that apply.)
- A. Abundant lanugo over the body
- B. Ear cartilage soft and pliable
- C. Flexed body posture
- D. Deep creases on the sole of the foot
Correct Answer: A
Rationale: Abundant lanugo over the body: Premature newborns often have abundant lanugo, which is fine, soft hair covering their bodies. This is a common characteristic of prematurity as the baby has not had enough time to shed this hair before birth.
What should nursing interventions to maintain a patent airway in a newborn include?
- A. Sleeping in the prone (on abdomen) position
- B. Wrapping neonate as snugly as possible
- C. Positioning neonate supine while sleeping
- D. Using bulb syringe to suction as needed, suctioning nose first, and then pharynx
Correct Answer: D
Rationale: Nursing interventions to maintain a patent airway in a newborn should prioritize safety and best practices. Positioning the neonate supine while sleeping is crucial to reduce the risk of sudden infant death syndrome (SIDS) and ensure proper airway alignment. Using a bulb syringe to suction as needed, with the correct technique of suctioning the nose first and then the pharynx, helps effectively remove secretions and keep the airway clear. This intervention promotes optimal respiratory function and reduces the risk of airway obstruction in newborns. Sleeping in the prone position is not recommended due to the increased risk of SIDS. Wrapping the neonate as snugly as possible can also pose risks of overheating and compromising the airway, making it an unsafe practice.
The baby with newly diagnosed diabetes is displaying shakiness, confusion, irritability, and slurred speech. What should the nurse suspect is happening?
- A. DKA
- B. Hypoglycemia
- C. HHS
- D. Hyperglycemia
Correct Answer: B
Rationale: The baby's symptoms of shakiness, confusion, irritability, and slurred speech are indicative of hypoglycemia, which is low blood sugar. In a baby with newly diagnosed diabetes, the administration of insulin or oral hypoglycemic agents may have led to excessive lowering of blood glucose levels, causing these symptoms to manifest. It is crucial to address hypoglycemia promptly by administering a rapid-acting carbohydrate source such as glucose gel or juice to raise blood sugar levels back to normal range. Left untreated, severe hypoglycemia can lead to seizures, loss of consciousness, and potential long-term neurological damage. It is important for healthcare providers and caregivers to be vigilant in monitoring blood glucose levels in babies newly diagnosed with diabetes to prevent episodes of hypoglycemia.
The physician orders local application of epinephrine 1:1000 solution to treat a nosebleed. The patient asks how this will help. Which of the ff. responses by the nurse is best?
- A. "It will raise you BP, which is necessary because of blood loss."
- B. "It will dilate your bronchioles and make your breathing easier."
- C. "It will help your blood to clot to reduce bleeding."
- D. "It will constrict your vessels and slow down the bleeding."
Correct Answer: D
Rationale: Epinephrine is a vasoconstrictor, which means it causes blood vessels to narrow. When applied locally to the site of a nosebleed, epinephrine constricts the blood vessels in the nose, slowing down and stopping the bleeding. By constricting the blood vessels, epinephrine helps to reduce the blood flow to the area, allowing a clot to form and stop the bleeding. This is why option D, "It will constrict your vessels and slow down the bleeding," is the best response by the nurse to explain how epinephrine will help treat a nosebleed.
Alveolar type of rhabdomyosarcoma accounts for approximately 1/3 of all cases of pediatric RMS and carries the poorest prognosis. Of the following, the MOST common site of involvement by alveolar type RMS is
- A. orbit
- B. middle ear
- C. extremities
- D. bladder
Correct Answer: C
Rationale: Extremities are the most common site for alveolar rhabdomyosarcoma.