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A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct answer is A. Infants with severe dehydration may not produce tears due to lack of fluid. This indicates the need for IV fluid therapy to rehydrate the baby. Lack of tears is a sign of significant dehydration in infants.
Option B, decreased heart rate, is not a specific sign of dehydration in infants and not a direct indication for IV fluids. Option C, slow breathing, is also not a direct indication of dehydration, as infants may have varied respiratory rates for other reasons. Option D, bulging fontanels, can be a sign of increased intracranial pressure but is not a direct indication for IV fluids in this context.
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A nurse is providing discharge teaching about car seat safety to a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I will position my baby at a 45-degree angle in the car seat.
- B. I can place my baby in the front seat with the airbag turned off.
- C. I can turn my baby's car seat around when she weighs 15 pounds.
- D. I will place my baby in a forward-facing car seat in my back seat.
Correct Answer: A
Rationale: Correct Answer: A. "I will position my baby at a 45-degree angle in the car seat."
Rationale: Placing the newborn at a 45-degree angle in the car seat supports the baby's airway and prevents slumping, ensuring proper breathing and safety. This position helps reduce the risk of suffocation and allows the baby's head to be supported. It is recommended by pediatric experts as the safest way for a newborn to travel in a car seat.
Summary of other choices:
B: Placing a baby in the front seat with the airbag turned off is not safe, as the back seat is the safest place for children under 13 years old.
C: Turning the baby's car seat around at 15 pounds is incorrect as rear-facing is recommended until at least 2 years of age.
D: Using a forward-facing car seat for a newborn is unsafe, as infants should be in a rear-facing seat until they outgrow the height or weight limit.
complete the following sentence by using the lists of options. The client is at highest risk for developing ---evidenced by the client's ---
- A. Endometritis.
- B. Mastitis.
- C. Postpartum hemorrhage.
- D. Group B streptococcus positive status.
- E. Spontaneous vaginal delivery.
- F. Median episiotomy.
Correct Answer: A
Rationale: The correct answer is A: Endometritis. The client is at highest risk for developing endometritis evidenced by the client's median episiotomy. Endometritis is an infection of the lining of the uterus and is commonly associated with invasive procedures like episiotomy. The incision from a median episiotomy provides a pathway for bacteria to enter the uterus, increasing the risk of infection. The other choices are incorrect because mastitis is related to breastfeeding, postpartum hemorrhage is excessive bleeding after childbirth, group B streptococcus positive status is a risk for neonatal infection, and spontaneous vaginal delivery is a mode of delivery not directly related to endometritis.
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, potentially leading to fetal distress. Oxytocin can further stress the fetus by increasing uterine contractions, exacerbating the late decelerations. Late decelerations are a sign of decreased oxygen supply to the fetus, making it unsafe to augment labor with oxytocin. Therefore, this finding should be reported to the provider to ensure the safety of both the client and the fetus.
Incorrect choices:
B: Moderate variability of the FHR is a reassuring sign of fetal well-being, not a contraindication for oxytocin infusion.
C: Cessation of uterine dilation may indicate a stalled labor progress but is not a contraindication for initiating oxytocin.
D: Prolonged active phase of labor may warrant augmentation with oxytocin rather than being a contraindication.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic sac. Monitoring the client's temperature is crucial as fever can indicate infection, which can be life-threatening for both the client and the fetus. It is essential to detect early signs of infection to initiate prompt treatment. Assessing O2 saturation, blood pressure, and urinary output are important but not the priority in this situation. O2 saturation may be monitored if there are concerns about fetal distress, blood pressure for signs of preeclampsia, and urinary output for kidney function, but these are not immediate concerns post-amniotomy.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns born at 26 weeks of gestation, they typically exhibit minimal arm recoil due to their immature neuromuscular development. This is a key characteristic assessed in the New Ballard Score to determine the gestational age of the newborn. Choices B, C, and D are incorrect as they do not align with the expected findings in a premature newborn at 26 weeks of gestation. Popliteal angle of 90° (Choice B) is more typical in a term newborn. Creases over the entire foot sole (Choice C) are also more common in term newborns. Raised areolas with 3 to 4 mm buds (Choice D) are indicative of a more mature newborn and not typically seen in a premature newborn at 26 weeks of gestation.