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A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which of the following is an appropriate response by the nurse?
- A. You can push the baby to the room in a wheeled bassinet.
- B. If you show me your photo identification, you can take the infant.
- C. Have the mother ring, and I will take the baby to the room.
- D. You may carry your grandchild to the room.
Correct Answer: C
Rationale: The correct response is C: Have the mother ring, and I will take the baby to the room. This is the appropriate response because it ensures the safety and security of the newborn by confirming the mother's approval before allowing the grandmother to take the baby to the room. This step is crucial to prevent any unauthorized individuals from taking the baby without the mother's consent.
Choice A is incorrect because pushing the baby to the room in a wheeled bassinet may not involve verifying the mother's consent. Choice B is incorrect as asking for photo identification does not confirm the mother's approval. Choice D is incorrect as it assumes the grandmother can carry the baby without checking with the mother first.
In summary, choice C is the correct response as it prioritizes the safety and well-being of the newborn by ensuring the mother's consent is obtained before allowing the grandmother to take the baby to the room.
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A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Select all that apply:
- A. Antibiotic ointment to both eyes
- B. Hepatitis B immunization
- C. Lidocaine gel to the umbilical stump
- D. Haemophilus influenzae type b immunization
- E. Vitamin K injection
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A: Antibiotic ointment to both eyes is given to prevent neonatal conjunctivitis. B: Hepatitis B immunization is crucial for newborns to prevent Hepatitis B infection. E: Vitamin K injection is given to prevent hemorrhagic disease of the newborn. C: Lidocaine gel to the umbilical stump is not a standard practice and can cause local irritation. D: Haemophilus influenzae type b immunization is typically given later in infancy, not immediately after birth.
A nurse is preparing to administer magnesium sulfate to a client. Which of the following is the priority nursing assessment for this client?
- A. Bowel sounds
- B. Respiratory rate
- C. Temperature
- D. Fetal heart rate (FHR)
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate. Magnesium sulfate is a medication that can cause respiratory depression. Monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress or depression promptly. This assessment is a priority because respiratory depression can lead to serious complications, including respiratory arrest. Assessing bowel sounds (choice A), temperature (choice C), and fetal heart rate (choice D) are important but not as critical as monitoring the respiratory rate when administering magnesium sulfate. Bowel sounds may indicate gastrointestinal motility issues, temperature changes may indicate infection, and fetal heart rate is important in pregnancy but not the priority when administering magnesium sulfate.
A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Place the client in knee-chest position.
- C. Prepare the client for an immediate birth.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord.
Correct Answer: D
Rationale: The correct answer is D: Insert a gloved hand into the vagina to relieve pressure on the cord. This is the priority action in this situation to prevent cord compression, which can compromise fetal blood flow. By gently elevating the presenting part off the cord, the nurse can help restore blood flow to the baby. Covering the cord (A) or placing the client in the knee-chest position (B) are not as effective in relieving pressure on the cord. Preparing for an immediate birth (C) may be necessary but addressing the cord issue is the priority.
A nurse is caring for a client who is in premature labor and is receiving terbutaline. The nurse should monitor the client for which of the following adverse effects that should be reported to the provider?
- A. Dyspnea
- B. Headaches
- C. Nervousness
- D. Tremors
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Terbutaline is a beta-adrenergic agonist that can cause pulmonary edema as a serious adverse effect. Dyspnea is a common symptom of pulmonary edema, indicating potential respiratory distress. This adverse effect should be reported promptly to the provider for further evaluation and management to prevent complications.
Incorrect choices:
B: Headaches - Headaches are a common side effect of terbutaline but are not as concerning as respiratory distress.
C: Nervousness - Nervousness is a common side effect of terbutaline and does not typically require immediate reporting unless severe.
D: Tremors - Tremors are a common side effect of terbutaline and are not as concerning as respiratory distress.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. This is a cephalohematoma which can occur spontaneously.
- B. A caput succedaneum will subside in a few days.
- C. Mongolian spots can be found on the skin of many newborns.
- D. This is a telangiectatic nevus and no treatment is needed.
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines. Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum. Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.