Nokea
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Select all that apply:
- A. Antibiotic ointment to both eyes
- B. Hepatitis B immunization
- C. Lidocaine gel to the umbilical stump
- D. Haemophilus influenzae type b immunization
- E. Vitamin K injection
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A: Antibiotic ointment to both eyes is given to prevent neonatal conjunctivitis. B: Hepatitis B immunization is crucial for newborns to prevent Hepatitis B infection. E: Vitamin K injection is given to prevent hemorrhagic disease of the newborn. C: Lidocaine gel to the umbilical stump is not a standard practice and can cause local irritation. D: Haemophilus influenzae type b immunization is typically given later in infancy, not immediately after birth.
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A nurse is caring for a client who is at 40 weeks of gestation and is in labor. The client’s ultrasound examination indicates that the fetus is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care after birth?
- A. Observe for meconium in respiratory secretions.
- B. Monitor for hyperthermia.
- C. Identify manifestations of anemia.
- D. Monitor for hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Observe for meconium in respiratory secretions. This is important because infants who are small for gestational age (SGA) are at increased risk for meconium aspiration syndrome due to their underdeveloped lungs. Meconium in respiratory secretions can lead to respiratory distress and requires immediate intervention.
Choice B, monitoring for hyperthermia, is incorrect as it is not specifically related to SGA infants. Choice C, identifying manifestations of anemia, is also incorrect as SGA infants may have normal hematologic parameters. Choice D, monitoring for hyperglycemia, is not directly associated with SGA infants and is more relevant to infants of diabetic mothers.
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.
The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant?
- A. Encouraging the mother to supplement breast-feeding with formula.
- B. Keeping the infant NPO until the second period of reactivity.
- C. Encouraging the mother to breastfeed the infant every 2 to 3 hours.
- D. Placing the infant under phototherapy.
Correct Answer: C
Rationale: The correct answer is C: Encouraging the mother to breastfeed the infant every 2 to 3 hours. Breastfeeding frequently helps prevent jaundice by promoting the excretion of bilirubin through stool. This helps prevent bilirubin buildup in the baby's body, reducing the risk of jaundice. Encouraging frequent breastfeeding also ensures the infant receives adequate hydration, which aids in the elimination of bilirubin.
Choice A is incorrect because supplementing with formula can interfere with breastfeeding and affect bilirubin excretion. Choice B is incorrect because keeping the infant NPO can lead to dehydration and decreased bilirubin excretion. Choice D is incorrect because phototherapy is a treatment for jaundice, not prevention.
A nurse observes 5 minutes after delivery that a newborn has a pink trunk and head, bluish hands and feet, and a heart rate of 130/min. He has flexed extremities and a weak, slow cry. The nurse should document what Apgar score for this infant?
- A. 5
- B. 6
- C. 7
- D. 8
- E. 9
Correct Answer: B
Rationale: The correct Apgar score for this infant is B: 6. The Apgar score assesses a newborn's overall condition at 1 and 5 minutes after birth based on five criteria: Appearance, Pulse, Grimace, Activity, and Respiration. In this case, the baby has a pink trunk and head (2 points), bluish hands and feet (1 point), a heart rate of 130/min (2 points), flexed extremities (2 points), and a weak, slow cry (1 point). Adding these points together, the Apgar score is 2+1+2+2+1=8. Since the Apgar score ranges from 0 to 10, a score of 6 indicates that the infant may need some assistance but is generally in good condition. Other choices are incorrect because they do not add up correctly based on the described criteria.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.