Nokea
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: Verifying the newborn's identification is the first priority to ensure that the correct newborn is receiving care, especially in a busy nursery setting.
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A nurse is performing an initial assessment of a newborn. Which of the following actions should the nurse take to prevent any heat loss through conduction?
- A. Cover the scale with a warmed blanket before weighing the baby
- B. Evaluate respirations by observing the newborn's uncovered chest for 1 min.
- C. Place the newborn's crib away from of an air vent to perform the assessment.
- D. Perform the assessment immediately after birth before removing amniotic fluid.
Correct Answer: A
Rationale: Covering the scale with a warmed blanket prevents heat loss through conduction, which occurs when the newborn comes into contact with a cold surface.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia
- B. Increased feeding
- C. Hyperthermia
- D. Respiratory distress
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to inadequate energy supply to the respiratory muscles, resulting in respiratory distress. Hypertonia (A) is not a typical manifestation of hypoglycemia in newborns. Increased feeding (B) is a common response to hunger but not a direct indication of hypoglycemia. Hyperthermia (C) is not a typical sign of hypoglycemia. In summary, respiratory distress is a key clinical manifestation of hypoglycemia in late preterm newborns, making it the correct choice.
What is the recommended method of administering vitamin K to a newborn?
- A. Intramuscular injection
- B. Oral administration
- C. Topical application
- D. Subcutaneous injection
Correct Answer: A
Rationale: The correct method is A: Intramuscular injection. This route ensures rapid and reliable absorption of vitamin K, crucial for preventing bleeding disorders in newborns. Oral administration may be less effective due to variable absorption. Topical application is not recommended as it may not provide sufficient absorption. Subcutaneous injection can lead to variable absorption rates and is not as reliable as the intramuscular route for vitamin K administration.
Which of the following is a potential complication of neonatal hypoglycemia?
- A. Jaundice
- B. Respiratory distress syndrome
- C. Intraventricular hemorrhage
- D. All of the above
Correct Answer: D
Rationale: Neonatal hypoglycemia can lead to jaundice, respiratory distress syndrome, and intraventricular hemorrhage.
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is appropriate because the occipitoposterior position often leads to back labor due to the baby's position pressing on the mother's spine. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve pressure on the mother's back.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is more effective for back pain relief, not suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for addressing back pain, not pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect as the position change is unlikely to affect the timing of contractions significantly.
In summary, the correct question (Choice D) directly addresses the main issue associated with occipitoposterior