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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 in a newborn indicate respiratory distress and can be a sign of underlying respiratory issues such as respiratory distress syndrome. The nurse should report this finding to the provider immediately for further evaluation and intervention to ensure the newborn's respiratory status is stable. Acrocyanosis (choice B) is a common finding in newborns and is not typically concerning. Overlapping suture lines (choice C) can be a normal variation in newborn skull anatomy. The head circumference of 33 cm (13 in) (choice D) is within the normal range for a newborn and would not require immediate reporting.
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What is the recommended method of administering vitamin D to a breastfed newborn?
- A. Intramuscular injection
- B. Oral drops
- C. Topical application
- D. Subcutaneous injection
Correct Answer: B
Rationale: Oral drops are the recommended method for administering vitamin D to breastfed newborns.
A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?
- A. Apply pressure to the client's fundus.
- B. Press firmly on the client’s suprapubic area.
- C. Move the client onto their hands and knees.
- D. Assist the client in pulling their knees toward their abdomen.
Correct Answer: D
Rationale: The correct answer is D: Assist the client in pulling their knees toward their abdomen. In shoulder dystocia, the baby's shoulder is stuck behind the mother's pubic bone. The McRoberts maneuver involves hyperflexing the mother's legs towards her abdomen to enlarge the pelvic outlet, which can help dislodge the shoulder and facilitate delivery. This action can help create more space for the baby to maneuver and be born. Applying pressure to the fundus (A) does not address the mechanical issue of shoulder dystocia. Pressing on the suprapubic area (B) may not provide the necessary space for the baby to be delivered. Moving the client onto their hands and knees (C) may not be as effective as the McRoberts maneuver in this situation.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. "I should increase my protein intake to 60 grams each day."
- B. "I should drink 2 liters of water each day."
- C. "I should increase my overall daily caloric intake by 300 calories."
- D. "I should take 600 micrograms of folic acid each day."
Correct Answer: A
Rationale: Increasing protein intake to 60 grams daily is essential during pregnancy to support fetal growth and maternal tissue expansion. This aligns with nutritional guidelines for pregnancy.
Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Coombs test result
- B. Mucous membrane assessment
- C. Intake and output
- D. Respiratory rate
- E. Head assessment finding
- F. Heart rate
- G. Sclera color
Correct Answer: A,B,C,G
Rationale:
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the client NPO throughout the procedure.
- B. Place the client in a supine position.
- C. Instruct the client to massage the abdomen to stimulate fetal movement.
- D. Instruct the client to press the provided button each time fetal movement is detected.
Correct Answer: D
Rationale: Pressing the button each time fetal movement is detected helps monitor fetal well-being by correlating movement with heart rate accelerations, which is the purpose of a nonstress test.