Nokea
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?
- A. Accidental lacerations
- B. Respiratory distress
- C. Hypothermia
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Respiratory distress. The nurse's priority is to ensure the newborn's ability to breathe effectively. Respiratory distress is common after cesarean delivery due to fluid in the lungs. Addressing this promptly is critical to prevent complications. Accidental lacerations (A) are important but not immediately life-threatening. Hypothermia (C) can be addressed after ensuring the newborn's respiratory status. Acrocyanosis (D) is a common finding in newborns and not an urgent concern.
You may also like to solve these questions
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use
- B. Blunt force trauma
- C. Hypertension
- D. Cigarette smoking
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption because it can lead to reduced blood flow to the placenta, increasing the risk of separation. High blood pressure can cause damage to the blood vessels in the placenta, making it more susceptible to detachment. Cocaine use (A) and cigarette smoking (D) can also increase the risk of abruption, but they are not as common as hypertension. Blunt force trauma (B) can directly cause placental abruption but is not as prevalent as hypertension in this context.
A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?
- A. Assess maternal blood glucose.
- B. Discontinue the magnesium infusion.
- C. Prepare for an emergency cesarean birth.
- D. Place the client in Trendelenburg position.
Correct Answer: B
Rationale: Correct Answer: B - Discontinue the magnesium infusion.
Rationale: A respiratory rate of 10/min indicates respiratory depression, a common adverse effect of magnesium sulfate. Discontinuing the infusion is crucial to prevent further respiratory compromise and potential respiratory arrest. This action takes precedence over other interventions as it addresses the immediate risk to the client's safety.
Summary of other choices:
A: Assessing maternal blood glucose is unrelated to the client's respiratory rate and immediate need for intervention.
C: Emergency cesarean birth is not indicated based solely on the respiratory rate and magnesium sulfate administration.
D: Placing the client in Trendelenburg position is not appropriate for respiratory depression and may worsen the situation.
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.
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 on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
- A. Drying the newborn’s skin thoroughly.
- B. Preventing air drafts.
- C. Placing the newborn on a warm surface.
- D. Maintaining ambient room temperature at 24°C (75.2°F).
Correct Answer: A
Rationale: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (B) and placing the newborn on a warm surface (C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (D) is important for thermoregulation but does not directly address evaporative heat loss.