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A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to inadequate energy supply to the respiratory muscles, resulting in respiratory distress. Hypertonia (A) is not a typical manifestation of hypoglycemia in newborns. Increased feeding (B) is a common response to hunger but not a direct indication of hypoglycemia. Hyperthermia (C) is not a typical sign of hypoglycemia. In summary, respiratory distress is a key clinical manifestation of hypoglycemia in late preterm newborns, making it the correct choice.
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A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: Ensuring that the parent's identification band number matches the newborn's identification band number is a critical safety measure to prevent errors in newborn identification.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This is the correct action because the steady trickle of vaginal bleeding coupled with ineffective fundal massage indicates postpartum hemorrhage, which can lead to hypovolemic shock. Administering a lactated Ringer's IV bolus helps to replace lost fluids and maintain hemodynamic stability.
Other choices are incorrect:
A: Replacing the surgical dressing does not address the underlying issue of postpartum hemorrhage.
B: Evaluating urinary output is important but not the priority when the client is experiencing postpartum hemorrhage.
C: Applying an ice pack to the incision site is not appropriate for managing postpartum hemorrhage.
Overall, in this scenario, administering IV fluids is the most critical intervention to address the potential life-threatening complication of postpartum hemorrhage.
A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)
- A. Flaccid uterus
- B. Cervical laceration
- C. Excess vaginal bleeding
- D. Increased afterbirth cramping
Correct Answer: A,C
Rationale: The correct answers are A and C. A flaccid uterus indicates poor uterine tone, which can lead to postpartum hemorrhage. Oxytocin is given to enhance uterine contractions and tone, helping prevent excessive bleeding. Excess vaginal bleeding is also an indication for oxytocin administration as it can help control bleeding by promoting uterine contractions. Choices B, D, and other options are incorrect as they do not directly relate to the need for oxytocin administration in this scenario. Cervical laceration and increased afterbirth cramping may require other interventions, but they do not specifically indicate the need for oxytocin administration to address postpartum bleeding.
A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?
- A. Vomiting
- B. Hypertension
- C. Epigastric pain
- D. Contractions
Correct Answer: D
Rationale: Contractions can indicate preterm labor, a potential complication following amniocentesis. Vomiting, hypertension, and epigastric pain are less directly related to the procedure.
A nurse is caring for a client who is 12 hr postpartum and has a third-degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer?
- A. Bisacodyl 10 mg rectal suppository
- B. Magnesium hydroxide 30 mL PO
- C. Famotidine 20 mg PO
- D. Loperamide 4 mg PO
Correct Answer: A
Rationale: A rectal suppository like bisacodyl is effective for relieving constipation and is safe for postpartum clients with perineal lacerations.