Nokea
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis
- B. Transient strabismus
- C. Jaundice
- D. Caput succedaneum
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn 12 hours after birth could indicate physiological jaundice, but it should still be reported to the provider for further evaluation. Jaundice can be a sign of hyperbilirubinemia, which if left untreated, can lead to complications like kernicterus. Acrocyanosis (A), transient strabismus (B), and caput succedaneum (D) are common and expected findings in newborns and do not typically require immediate reporting unless they are severe or persistent.
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A nurse is providing care for a 2-day-old neonate with a cleft lip and palate. The nurse evaluates the parents' understanding of correct feeding methods. Which of the following observations indicates a need for further teaching?
- A. Uses a long,soft nipple with a cross-cut opening attached to a bottle.
- B. When breastfeeding
- C. Uses an eyedropper with a piece of rubber tubing on the tip.
- D. Obtains a 'gravity flow' nipple and attaches it to a squeezable plastic bottle.
Correct Answer: B
Rationale: Positioning the nipple toward the front makes sucking more difficult for infants with cleft palate.
A multiparous woman with a history of all vaginal births is admitted to the hospital in labor. After several hours, the client's labor has not progressed and she is getting tired and restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the client's knowledge deficit regarding the surgical delivery and care after birth. Which is the appropriate expected outcome for correction of the client's knowledge deficit? The client will:
- A. Demonstrate appropriate coping mechanisms needed to get through the surgery.
- B. Accept that the type of delivery will not affect the bonding with the baby.
- C. Verbalize understanding about the reason for the unplanned surgery.
- D. Demonstrate decreased anxiety and fear of the unknown.
Correct Answer: C
Rationale: The correct answer is C: Verbalize understanding about the reason for the unplanned surgery. This outcome focuses on the client understanding why the cesarean delivery is necessary, which is crucial for informed decision-making and reducing anxiety. It shows the client comprehends the situation, which is important for her emotional well-being and cooperation during the procedure and postpartum period. Option A is incorrect because coping mechanisms are important but not directly related to knowledge deficit correction. Option B is incorrect as it does not address the client's knowledge deficit but rather focuses on emotional aspects. Option D is incorrect as it addresses anxiety and fear but not the underlying issue of knowledge deficit.
During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate?
- A. Hold the presenting part away from the cord
- B. Insert a scalp electrode for an internal fetal monitor
- C. Place the client in reverse Trendelenburg position
- D. Cover the cord with a dry,sterile gauze
Correct Answer: A
Rationale: The correct answer is A: Hold the presenting part away from the cord. This action helps relieve pressure on the cord, preventing further compromise of blood flow to the fetus. It is crucial to maintain fetal perfusion. Choice B (Insert a scalp electrode) and D (Cover the cord with gauze) are not appropriate as they do not address the immediate risk of cord compression. Choice C (Reverse Trendelenburg) may worsen the prolapse by shifting the presenting part higher.
During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of 'pain related to perineal sutures.' Which nursing intervention is most appropriate during the first 24 hours following an episiotomy?
- A. Instruct the client to use petroleum jelly on the episiotomy after voiding.
- B. Encourage the client to practice Kegel exercises.
- C. Advise the client to take a warm sitz bath every four hours.
- D. Apply ice packs to the perineum.
Correct Answer: D
Rationale: The correct answer is D: Apply ice packs to the perineum. Ice packs help reduce swelling and provide numbing relief, which can help alleviate pain in the immediate postpartum period. Applying ice packs during the first 24 hours can also promote vasoconstriction, reducing the risk of bleeding and infection.
Incorrect options:
A: Using petroleum jelly can increase the risk of infection and hinder wound healing.
B: Kegel exercises are beneficial for pelvic floor strengthening but are not the most appropriate intervention for immediate pain relief.
C: While sitz baths can be soothing, they may not be suitable within the first 24 hours post-episiotomy as they can increase blood flow and potentially worsen swelling.
Overall, ice packs are the most effective and appropriate intervention for pain management in the immediate postpartum period.
A nurse is caring for a 4-month-old infant with thrush (candidiasis) who is breastfed.
- A. "Administer the prescribed nystatin (Mycostatin) for 2 to 3 days after the lesions disappear."'
- B. "Place the infant on a soy-based formula to supplement breastfeeding until thrush is resolved."'
- C. "Discontinue breastfeeding and resume 48 hr after the last lesion disappears."'
- D. "Scrape off the white patches of thrush from the oral mucous membrane with a tongue depressor."'
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Nystatin is an antifungal medication commonly used to treat thrush in infants. It is safe for infants and effective against Candida. The treatment should be continued for 2 to 3 days after the lesions disappear to ensure complete eradication of the infection. Discontinuing the medication prematurely can lead to a recurrence of thrush.
Summary of other choices:
B: Switching to a soy-based formula is unnecessary and does not address the thrush infection directly.
C: Discontinuing breastfeeding is not necessary and can disrupt the infant's feeding routine.
D: Scraping off the white patches can cause trauma to the oral mucosa and should be avoided.