Nokea
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D because delaying the instillation of antibiotic ophthalmic ointment can facilitate bonding between the newborn and parent, promoting skin-to-skin contact and eye contact essential for bonding. This crucial time immediately following birth sets the foundation for a strong parent-child relationship.
Summary:
A: Incorrect. Delaying antibiotic ointment instillation does not help in identifying infection manifestations.
B: Incorrect. The newborn's weight is not a factor in delaying the instillation of ointment.
C: Incorrect. The mode of delivery does not impact the timing of antibiotic ointment application.
D: Correct. Delaying ointment instillation facilitates bonding between the newborn and parent.
E, F, G: N/A
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A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics.
- B. Monitor the rectal temperature every 4 hr.
- C. Cleanse the site with povidone-iodine.
- D. Prepare for surgical closure after 72 hr.
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. The leaking cerebrospinal fluid puts the newborn at risk for infection, so administering antibiotics helps prevent infection. Monitoring rectal temperature (B) is not directly related to preventing infection. Cleansing the site with povidone-iodine (C) may not be effective in preventing infection. Preparing for surgical closure after 72 hr (D) is important but addressing the risk of infection with antibiotics is the immediate priority.
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: The correct answers to report to the provider are A, B, C, and G.
A: Coombs test result is crucial for diagnosing hemolytic anemia.
B: Mucous membrane assessment reflects hydration and oxygenation status.
C: Intake and output are vital for monitoring fluid balance.
G: Sclera color can indicate jaundice or liver dysfunction.
Other choices like D, E, and F are important assessments but not as critical for immediate provider notification. The respiratory rate (D) and heart rate (F) are essential vital signs but can be monitored routinely. Head assessment findings (E) can be important but may not require immediate provider notification unless there is a significant change.
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This is important because the lateral side has fewer nerve endings, making it less painful for the client. Additionally, it reduces the risk of injury to the nerves and blood vessels located on the other sides of the finger. Puncturing the finger while still damp with antiseptic solution (choice A) can dilute the blood sample and affect accuracy. Smearing the blood onto the reagent strip (choice B) may lead to inaccurate results due to improper application. Holding the finger above the heart prior to puncture (choice C) can increase blood flow and potentially affect the glucose level. Therefore, selecting the lateral side of the finger for puncture is the best practice for obtaining a 2-hr postprandial blood glucose sample.
A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele’s Rule, which of the following is the client’s estimated date of delivery?
- A. May 13
- B. May 17
- C. May 3
- D. May 20
Correct Answer: B
Rationale: The correct answer is B: May 17. Nägele's Rule involves adding 7 days to the first day of the last menstrual period, subtracting 3 months, and adding 1 year. In this case, August 10 + 7 days = August 17, subtracting 3 months gives May 17. This calculation estimates the date of delivery. Choice A (May 13) is incorrect as it doesn't account for the full calculation process. Choice C (May 3) is incorrect as it doesn't consider adding 7 days. Choice D (May 20) is incorrect as it doesn't involve subtracting 3 months.
A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?
- A. Limit the amount of time the fetus is in the client’s room.
- B. Provide the client with photos of the fetus.
- C. Instruct the client that an autopsy should be performed within 24 hr.
- D. Inform the client that the law requires them to name the fetus.
Correct Answer: B
Rationale: The correct answer is B: Provide the client with photos of the fetus. This action allows the client to have tangible memories of their stillborn child, which can aid in the grieving process and provide closure. Providing photos is a sensitive and compassionate gesture that acknowledges the significance of the loss. It also respects the client's autonomy in choosing how they wish to remember their child.
The other choices are not appropriate in this situation:
A: Limiting the time the fetus is in the room may not consider the emotional needs of the client.
C: Instructing the client about an autopsy may be insensitive and distressing without discussing it first with the client.
D: Informing the client about naming the fetus is not a legal requirement and could add unnecessary pressure during a difficult time.