Nokea
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling “down” and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?
- A. Ask the client if she has considered harming her newborn.
- B. Anticipate a prescription by the provider for an antidepressant.
- C. Reinforce postpartum and newborn care discharge teaching.
- D. Assist the family to identify proper use of positive coping skills in family crises.
Correct Answer: A
Rationale: The correct answer is A. The nurse should ask the client if she has considered harming her newborn as she is experiencing symptoms of postpartum depression. This is a critical step to assess the client's safety and the baby's well-being. Other choices are incorrect as B assumes the need for medication without further assessment, C focuses on teaching rather than immediate safety concerns, and D does not address the client's mental health state. By asking about harming the newborn, the nurse can assess the severity of the client's condition and provide appropriate interventions.
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A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?
- A. Intercostal space
- B. Xiphoid process
- C. Sternal notch
- D. Nipple line
Correct Answer: D
Rationale: The correct answer is D: Nipple line. When measuring a newborn's chest circumference, the nurse should use the nipple line as the anatomical landmark. This is because the nipple line is a consistent and reliable reference point for chest measurements in newborns. The other choices are not suitable landmarks for chest circumference measurement in newborns. A: Intercostal space is not a specific point for measurement. B: Xiphoid process is too low and not commonly used for chest measurements. C: Sternal notch is not a precise point for chest circumference measurement in newborns. Therefore, D: Nipple line is the most appropriate anatomical landmark for accurate chest circumference measurement in newborns.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?
- A. Accidental lacerations
- B. Respiratory distress
- C. Hypothermia
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Respiratory distress. The nurse's priority is to ensure the newborn's ability to breathe effectively. Respiratory distress is common after cesarean delivery due to fluid in the lungs. Addressing this promptly is critical to prevent complications. Accidental lacerations (A) are important but not immediately life-threatening. Hypothermia (C) can be addressed after ensuring the newborn's respiratory status. Acrocyanosis (D) is a common finding in newborns and not an urgent concern.
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
- A. Drying the newborn’s skin thoroughly.
- B. Preventing air drafts.
- C. Placing the newborn on a warm surface.
- D. Maintaining ambient room temperature at 24°C (75.2°F).
Correct Answer: A
Rationale: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (B) and placing the newborn on a warm surface (C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (D) is important for thermoregulation but does not directly address evaporative heat loss.
An 8-pound 15-ounce baby born at 35 weeks’ gestation would be described using which terminology? Select all that apply.
- A. Small for gestational age
- B. Term
- C. Preterm
- D. Average for gestational age
- E. Post term
Correct Answer: C,D
Rationale: The correct answer is C and D. Choice C, "Preterm," is correct because a baby born at 35 weeks' gestation is considered preterm, as full term is typically around 39-40 weeks. Choice D, "Average for gestational age," is also correct because the baby's weight falls within the normal range for babies born at 35 weeks. Choice A, "Small for gestational age," is incorrect as the baby's weight is appropriate for its gestational age. Choice B, "Term," is incorrect because 35 weeks is considered preterm. Choice E, "Post term," is incorrect as it refers to a baby born after 42 weeks' gestation.
A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
- A. 5
- B. 6
- C. 7
- D. 8
- E. 9
Correct Answer: B
Rationale: The correct Apgar score for this infant is B: 6. The Apgar score assesses a newborn's overall condition at 1 and 5 minutes after birth based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. In this case, the baby has a pink trunk and head (2 points), bluish hands and feet (1 point), a heart rate of 130/min (2 points), flexed extremities (2 points), and a weak, slow cry (1 point). Adding these points together, the Apgar score is 2+1+2+2+1=8. Since the Apgar score ranges from 0 to 10, a score of 6 indicates that the infant may need some assistance but is generally in good condition. Other choices are incorrect because they do not add up correctly based on the described criteria.