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A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates is within the expected reference range for a newborn?
- A. 48/min
- B. 22/min
- C. 100/min
- D. 110/min
Correct Answer: A
Rationale: The correct answer is A: 48/min. The normal respiratory rate for a newborn is typically between 30-60 breaths per minute. Choice A falls within this range, indicating a normal respiratory rate for the newborn. Choices B, C, and D are outside the expected reference range. Choice B (22/min) is too low, while choices C (100/min) and D (110/min) are too high, which could indicate respiratory distress or other underlying issues in the newborn. It is important for the nurse to monitor the newborn closely and further assess if the respiratory rate is outside the normal range.
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The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?
- A. Turning on the apnea#nbsp;apnea and cardiorespiratory monitor.
- B. Connecting the resuscitation bag to oxygen.
- C. Setting up the radiant warmer control temperature at 36.4°C (97.5°F).
- D. Preparing for the insertion of an intravenous (IV) line with D5W.
Correct Answer: B
Rationale: The correct answer is B: Connecting the resuscitation bag to oxygen. This intervention is the priority because the infant has low Apgar scores, indicating poor oxygenation and respiratory effort. Providing oxygen through the resuscitation bag will help improve oxygenation and support the infant's breathing, which is crucial in the immediate postnatal period.
Turning on the apnea and cardiorespiratory monitor (Choice A) may be important for continuous monitoring but addressing the oxygenation issue takes precedence. Setting up the radiant warmer control temperature (Choice C) is important for maintaining the infant's body temperature but not the immediate priority. Preparing for IV insertion with D5W (Choice D) is not necessary at this moment as the priority is to address the respiratory distress.
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 97.6°F. Which of the following is the priority nursing action?
- A. Witness the signature for informed consent for surgery.
- B. Initiate IV access.
- C. Insert an indwelling urinary catheter.
- D. Prepare the abdominal and perineal areas.
Correct Answer: B
Rationale: The correct answer is B: Initiate IV access. The priority nursing action in this scenario is to ensure IV access to administer necessary medications or fluids in case of an emergency. The client's vital signs indicate hypotension and tachycardia, which could be signs of hypovolemic shock due to significant bleeding. Initiating IV access promptly can help stabilize the client's condition and prevent further complications.
Choice A is incorrect because obtaining informed consent for surgery is not the immediate priority in this situation. Choice C is incorrect as inserting a urinary catheter is not urgent compared to addressing the potential hypovolemia. Choice D is incorrect as preparing the abdominal and perineal areas is not as urgent as addressing the client's hemodynamic instability.
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 admitting a client who experienced a vaginal birth 2 hours ago. The client is receiving an IV of lactated Ringer’s with 25 units of oxytocin infusing and has large rubra lochia. Vital signs include blood pressure 146/94 mm Hg, pulse 80/min, and respiratory rate 18/min. The nurse reviews the prescriptions from the provider. Which of the following prescriptions requires clarification?
- A. Administer oxygen by non-rebreather mask at 5 L/min
- B. Obtain laboratory study of prothrombin and partial thromboplastin time
- C. Methylergonovine 0.2 mg IM now
- D. Insert an indwelling urinary catheter
Correct Answer: C
Rationale: The correct answer is C: Methylergonovine 0.2 mg IM now. This prescription requires clarification because methylergonovine is a uterotonic medication that can cause severe vasoconstriction, leading to increased blood pressure. Given the client's elevated blood pressure of 146/94 mm Hg, administering methylergonovine could potentially worsen hypertension and lead to adverse effects such as stroke or myocardial infarction. It is crucial to address the high blood pressure before considering the administration of methylergonovine. The other options are not immediately concerning: A) Administering oxygen is appropriate for a client with elevated blood pressure; B) Obtaining laboratory studies is a routine part of postpartum care to assess for coagulation abnormalities; D) Inserting an indwelling urinary catheter is commonly done postpartum to monitor urinary output.
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn’s maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?
- A. “There is no need to worry about that. Most forms of hearing loss are not inherited.”
- B. “We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital.”
- C. “The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.”
- D. “Look at how she looks at you when you speak. That’s a good sign.”
Correct Answer: B
Rationale: Rationale: Choice B is correct because routine hearing screenings for newborns are a standard practice to assess hearing ability. This screening is important for early detection and intervention if hearing loss is present. The other choices are incorrect because: A dismisses the client's concerns and provides inaccurate information, C is not a reliable method to assess hearing, and D, while somewhat accurate, does not provide a definitive assessment like a hearing screening would.