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A nurse is caring for a newborn who has a blood glucose level of 45 mg/dL. Which of the following actions should the nurse take?
- A. Encourage the mother to breastfeed the newborn
- B. Gavage feed 60 mL (2 oz) of glucose water
- C. Administer 10 mL of D5W via IV
- D. Recheck the glucose level in 2 hr
Correct Answer: A
Rationale: Encouraging the mother to breastfeed is appropriate, as breastfeeding can quickly raise blood glucose levels in newborns. A level of 45 mg/dL is often acceptable but should be monitored closely.
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A postpartum client's fundus is firm, 3 cm above the umbilicus and displaced to the right. Which of the following interventions should the nurse take?
- A. Massage the fundus
- B. Administer oxytocin
- C. Assist the client to void then reassess the fundus
- D. Notify the healthcare provider
Correct Answer: C
Rationale: Displacement of the uterus from the midline is often a sign of bladder distention. A full bladder can prevent the uterus from contracting properly, which could increase the risk of postpartum hemorrhage. The nurse should assist the client to void and then reassess the position and firmness of the fundus to ensure appropriate uterine contraction.
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: The car seat should remain rear-facing until at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant's head, neck, and spine.
A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct Answer: A
Rationale: Contractions that are too frequent or prolonged can lead to uterine hyperstimulation, which can compromise fetal oxygenation. The nurse should stop the oxytocin infusion to reduce contraction frequency and intensity.
A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
- A. Cephalohematoma
- B. Caput succedaneum
- C. Subdural hematoma
- D. Molding
Correct Answer: A
Rationale: A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It results from trauma during birth and typically resolves on its own.
A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby along with any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: The client should verify the identification badge of anyone removing their baby to ensure the infant's safety and prevent abduction, highlighting the importance of strict identification protocols in the hospital setting.