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 within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
You may also like to solve these questions
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will eat foods that taste good instead of balancing my meals.
- B. I will avoid having a snack before I go to bed each night.
- C. I will have a cup of hot tea with each meal.
- D. I will eliminate products that contain dairy from my diet.
Correct Answer: A
Rationale: The correct answer is A. By stating she will eat foods that taste good instead of balancing meals, the client demonstrates understanding of the need to prioritize eating to manage hyperemesis gravidarum. This choice indicates she recognizes the importance of maintaining adequate nutrition despite food aversions. Choice B is incorrect as avoiding bedtime snacks may worsen nausea. Choice C is incorrect as caffeine in tea can exacerbate nausea. Choice D is incorrect as dairy products are important for calcium and protein intake during pregnancy.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions.
- B. Acrocyanosis.
- C. Overlapping suture lines.
- D. Head circumference 33 cm (13 in).
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions indicate respiratory distress in a newborn, which can be a serious issue requiring immediate medical attention. Acrocyanosis (choice B) is a common finding in newborns and is not concerning. Overlapping suture lines (choice C) can be normal in newborns and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) is within the normal range for a newborn.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks of gestation, a positive contraction stress test indicates potential placental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, muscle tone, breathing, amniotic fluid volume, and heart rate reactivity. This test helps determine the need for immediate delivery.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood for genetic testing and not for assessing fetal well-being. Amnioinfusion (B) is used to increase amniotic fluid volume during labor and not for evaluating fetal well-being. Chorionic villus sampling (D) is an invasive prenatal diagnostic test for genetic abnormalities and not for assessing fetal well-being.
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 respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?
- A. Late decelerations.
- B. Moderate variability of the FHR.
- C. Cessation of uterine dilation.
- D. Prolonged active phase of labor.
Correct Answer: A
Rationale: The correct answer is A: Late decelerations. Late decelerations indicate uteroplacental insufficiency, meaning the baby is not getting enough oxygen during contractions. Administering oxytocin, which can further stress the baby by increasing contractions, can worsen the situation. Late decelerations are a sign of fetal distress and require immediate intervention.
B: Moderate variability of the FHR is a normal finding and does not contraindicate the initiation of oxytocin.
C: Cessation of uterine dilation would suggest a potential issue with labor progress but does not directly contraindicate oxytocin.
D: Prolonged active phase of labor may warrant oxytocin to augment contractions but is not a contraindication itself.