Nokea
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.
You may also like to solve these questions
A nurse concludes that the parent of a newborn is not showing positive indications of parent-infant bonding. The parent appears very anxious and nervous when asked to bring the newborn to the other parent. Which of the following actions should the nurse use to promote parent-infant bonding?
- A. Hand the parent the newborn and suggest that they change the diaper.
- B. Ask the parent why they are so anxious and nervous.
- C. Tell the parent that they will grow accustomed to the newborn.
- D. Provide reinforcement about infant care when the parent is present.
Correct Answer: D
Rationale: The correct answer is D because providing reinforcement about infant care when the parent is present can help build the parent's confidence and competence in caring for the newborn, which can enhance parent-infant bonding. By offering support and guidance during interactions with the newborn, the parent can feel more comfortable and connected to the baby.
A: Handing the parent the newborn and suggesting they change the diaper may increase their anxiety and not address the underlying issue of bonding.
B: Asking the parent why they are anxious and nervous is important but may not directly promote bonding without providing concrete support.
C: Telling the parent they will grow accustomed to the newborn does not actively support bonding or address the parent's current concerns.
In summary, choice D is the best option as it provides practical assistance and positive reinforcement to help the parent feel more confident in caring for the newborn, ultimately fostering parent-infant bonding.
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.
A healthcare professional is discussing risk factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the healthcare professional include in the teaching? (Select all that apply)
- A. Epidural anesthesia
- B. Urinary bladder catheterization
- C. Frequent pelvic examinations
- D. All of the Above
Correct Answer: D
Rationale: The correct answer is D (All of the Above). Epidural anesthesia can increase the risk of urinary retention leading to UTIs. Urinary bladder catheterization can introduce pathogens into the urinary tract. Frequent pelvic examinations can disrupt the natural flora and introduce bacteria. Therefore, all the conditions listed can contribute to an increased risk of urinary tract infections. The other choices (A, B, C) are incorrect because each of them individually presents a risk factor for UTIs, and selecting only one or two choices would not encompass the full range of risk factors that the healthcare professional should include in the teaching.
When calculating the Apgar score of a newborn at 1 minute after delivery, which of the following findings would result in a score of 6?
- A. 4
- B. 5
- C. 6
- D. 7
Correct Answer: C
Rationale: The Apgar score assesses the newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 6 at 1 minute indicates moderate difficulty in transitioning to extrauterine life. For a score of 6, the baby may have a heart rate below 100 bpm, weak respiratory effort, some muscle tone, grimacing reflex irritability, and a body with bluish extremities but normal body color. Choice C aligns with these criteria. Choices A, B, and D do not meet the requirements for a score of 6 as they represent either too low or too high values in one or more criteria, resulting in a different Apgar score.
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.