Nokea
A nurse is assessing a newborn 1 hour after birth. The newborn has acrocyanosis and a heart rate of 130 beats per minute. Which of the following actions should the nurse take?
- A. Place the newborn under a radiant warmer
- B. Apply oxygen
- C. Swaddle the newborn
- D. Reassess the newborn in 1 hour
Correct Answer: D
Rationale: Acrocyanosis, or bluish discoloration of the hands and feet, is a normal finding in newborns in the first few hours after birth. The nurse should continue to monitor the newborn and reassess after some time.
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Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct Answer: A
Rationale: Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature. This can result in hypoglycemia and metabolic acidosis if not addressed. The use of a radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications.
A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct Answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hr
- B. Apply moisturizing lotion to the newborn's skin every 4 hr
- C. Give the newborn 1 oz of glucose water every 4 hr
- D. Reposition the newborn every 2 to 3 hr
Correct Answer: D
Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin.
A laboring client's membranes have just ruptured. What is the nurse's next action?
- A. Assess fetal heart rate pattern
- B. Monitor uterine contractions
- C. Administer oxygen
- D. Prepare for delivery
Correct Answer: A
Rationale: When a client's membranes rupture, there is a risk that the umbilical cord could become compressed, affecting blood flow to the fetus. The nurse's priority action is to assess the fetal heart rate to ensure that the fetus is not in distress.
A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
- A. Cesarean birth
- B. Vaginal birth
- C. Anemia
- D. Multiparity
Correct Answer: A
Rationale: Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors include smoking, obesity, and a history of thromboembolism.