Nokea
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.
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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.
A nurse on a labor unit is admitting a client who reports painful contractions. The nurse determines that the contractions have a duration of 1 minute and a frequency of 3 minutes. The nurse obtains the following vital signs: fetal heart rate 130/min, maternal heart rate 128/min, and maternal blood pressure 92/54 mm Hg. Which of the following is the priority action for the nurse to take?
- A. Notify the provider of the findings.
- B. Position the client with one hip elevated.
- C. Ask the client if she needs pain medication.
- D. Have the client void.
Correct Answer: B
Rationale: The correct answer is B: Position the client with one hip elevated. This is the priority action because the client's contractions are frequent and of significant duration, indicating active labor. Elevating one hip can help improve fetal oxygenation and blood flow during contractions. It can also help optimize fetal positioning for a smoother labor process.
Choice A: Notifying the provider is important but not the priority at this moment. The nurse should first address immediate client needs.
Choice C: Asking about pain medication is important, but managing the client's positioning for labor progress takes precedence.
Choice D: Having the client void is a routine step in labor management but is not the priority action in this scenario.
A newborn is noted to have secretions bubbling out of the nose and mouth after delivery. What is the nurse's priority action?
- A. Suction the nose with a bulb syringe.
- B. Suction the mouth with a bulb syringe.
- C. Use a suction catheter with low negative pressure.
- D. Turn the newborn on their side.
Correct Answer: B
Rationale: The correct answer is B: Suction the mouth with a bulb syringe. This is the priority action because secretions in the mouth can obstruct the airway and lead to respiratory distress. Suctioning the mouth first helps clear the airway effectively. Suctioning the nose with a bulb syringe (choice A) may not address the immediate risk of airway obstruction. Using a suction catheter with low negative pressure (choice C) can be too strong for a newborn. Turning the newborn on their side (choice D) may not effectively address the airway obstruction from secretions in the mouth.
When assisting a client with breastfeeding, which of the following reflexes will promote the newborn to latch?
- A. Babinski
- B. Rooting
- C. Moro
- D. Stepping
Correct Answer: B
Rationale: The correct answer is B: Rooting. This reflex helps the newborn turn their head towards a stimulus, such as the mother's nipple, facilitating latching during breastfeeding. Babinski (A) is a reflex related to the sole of the foot, Moro (C) is a startle reflex, and Stepping (D) involves movements resembling walking. These reflexes do not directly support the latch during breastfeeding. Rooting reflex is the most relevant and essential reflex for successful breastfeeding initiation.
During Leopold maneuvers on a client in labor, which technique should be used by the nurse to identify the fetal lie?
- A. Apply palms of both hands to sides of the uterus
- B. Palpate the fundus of the uterus
- C. Grasp the lower uterine segment between thumb and fingers
- D. Stand facing the client's feet with fingertips outlining cephalic prominence
Correct Answer: B
Rationale: The correct answer is option B: Palpate the fundus of the uterus. This technique helps the nurse identify the fetal lie by feeling for the position of the baby's head or buttocks at the top of the uterus. By palpating the fundus, the nurse can determine whether the baby is in a vertex (head down) or breech (head up) position. This method is effective in assessing the fetal lie as it provides direct information about the baby's orientation within the uterus.
Option A is incorrect because applying palms to the sides of the uterus does not specifically help identify the fetal lie. Option C is incorrect as grasping the lower uterine segment does not provide information on the fetal lie. Option D is incorrect because standing facing the client's feet with fingertips outlining cephalic prominence is not a technique used to determine fetal lie.