Nokea
A nurse in the newborn nursery, assisting with data collection for a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant at which location?
- A. In the axillary area
- B. At the level of the nipples
- C. Two inches below the nipples
- D. At the level of the umbilicus
Correct Answer: B
Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head circumference. The average chest circumference is 30.5 to 33 cm (12-13 inches). When there is molding of the head, the head and chest measurements may be equal at birth. Placing the tape measure at the level of the nipples ensures accuracy and consistency in newborn assessment. Options A, C, and D are incorrect as the chest circumference is specifically measured at the level of the nipples to obtain precise measurements.
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A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?
- A. Contacting the registered nurse
- B. Documenting the findings
- C. Wrapping an extra blanket around the infant
- D. Placing the infant in an oxygen tent
Correct Answer: B
Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.
A patient has been diagnosed with diabetes mellitus. Which of the following is not a clinical sign of diabetes mellitus?
- A. Polyphagia
- B. Polyuria
- C. Metabolic acidosis
- D. Lower extremity edema
Correct Answer: D
Rationale: A-C are associated with diabetes mellitus.
After delivering a healthy newborn 1 hour ago, a nurse notes a woman's radial pulse rate is 55 beats/min. What action should the nurse take based on this finding?
- A. Reporting the finding to the healthcare provider immediately
- B. Helping the woman stay in bed and rest
- C. Documenting the finding
- D. Performing active and passive range-of-motion exercises
Correct Answer: C
Rationale: After delivery, bradycardia (pulse rate 50-70 beats/min) may occur, reflecting the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume, allowing a slower heart rate to provide adequate maternal circulation. A pulse rate of 55 beats/min falls within the normal range post-delivery, so there is no need to notify the healthcare provider immediately. It is important for the client to remain on bed rest in the immediate postpartum period to prevent complications. While range-of-motion exercises are beneficial for a client on bed rest, it is not the priority based on the data provided. Therefore, the most appropriate nursing action is to document the finding for accurate record-keeping and monitoring of the client's condition.
A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse provides the mother with which information?
- A. To monitor the infant for infection and, if a fever develops, to contact the pediatrician
- B. That the stools should be solid and pale yellow to light brown
- C. That this is normal for breastfed infants
- D. To decrease the number of feedings by two per day
Correct Answer: C
Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools, which is considered normal. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. It is essential for the mother to understand that seedy, mustard-yellow stools are expected in breastfed infants, indicating that there is no need for concern. Monitoring for infection as the first response without other symptoms can cause unnecessary anxiety. Decreasing the number of feedings without valid reasons can lead to inadequate nutrition for the newborn. Therefore, the correct advice for the nurse to provide in this scenario is that seedy, mustard-yellow stools are normal for breastfed infants, reassuring the mother and promoting proper understanding of newborn stool characteristics.
A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?
- A. Notifying the healthcare provider
- B. Stopping the oxytocin infusion
- C. Checking the woman's blood pressure and pulse
- D. Increasing the intravenous (IV) rate of the nonadditive solution
Correct Answer: B
Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.