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A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?
- A. Confirm the newborn's Apgar score.
- B. Verify the newborn's identification.
- C. Administer vitamin K to the newborn.
- D. Determine obstetrical risk factors.
Correct Answer: B
Rationale: The correct answer is B: Verify the newborn's identification. This should be done first to ensure the right baby is receiving care. Confirming the identity helps prevent errors in medication administration and procedures. Checking the identification is crucial for patient safety. The other options are not the first priority in this scenario. A: Confirming the Apgar score can wait until after ensuring the correct baby is being cared for. C: Administering vitamin K is important, but verifying identification takes precedence. D: Determining obstetrical risk factors can be done later once the baby's identity is confirmed.
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A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)
- A. Cholecystitis
- B. Hypertension
- C. Human papillomavirus
- D. Migraine headaches
- E. Anxiety Disorder
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. Cholecystitis is a contraindication due to the risk of gallbladder disease. Hypertension is a contraindication because estrogen in oral contraceptives can exacerbate hypertension. Migraine headaches are a contraindication due to the increased risk of stroke. Human papillomavirus and anxiety disorder are not contraindications for oral contraceptives.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
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 fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is because decreased temperature (B), lethargy (C), poor feeding (D), respiratory distress (E), and yellow sclera and oral mucosa (F) are consistent with hypoglycemia, hyperbilirubinemia, and sepsis. Decreased temperature can indicate hypoglycemia, lethargy and poor feeding can be seen in hypoglycemia and sepsis, respiratory distress can be a sign of sepsis, and yellow sclera and oral mucosa can be indicative of hyperbilirubinemia. Ecchymotic caput succedaneum is more related to birth trauma and is not specific to these conditions.
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement.
- B. Leakage of fluid from the vagina.
- C. Upper abdominal discomfort.
- D. Urinary frequency.
Correct Answer: B
Rationale: The correct answer is B: Leakage of fluid from the vagina. This finding could indicate an amniotic fluid leak, which is a potential complication following an amniocentesis. Amniotic fluid leakage can lead to infection and preterm labor. Increased fetal movement (choice A) is a normal sign of fetal well-being. Upper abdominal discomfort (choice C) and urinary frequency (choice D) are common after an amniocentesis and are not typically concerning unless severe or persistent.