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: The correct answer is B: Verify the newborn's identification. This is the first action the nurse should take because ensuring proper identification is crucial for providing safe and effective care. By verifying the newborn's identification, the nurse can confirm they are caring for the right baby, preventing any potential errors in treatment or medication administration. This step is essential in maintaining patient safety and preventing harm.
Confirming the Apgar score (choice A) can be important but is not the first priority in this scenario. Administering vitamin K (choice C) is a routine procedure but can be done after verifying identification. Determining obstetrical risk factors (choice D) is important for overall assessment but is not the immediate priority.
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A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Abdominal assessment
- B. Vaginal discharge
- C. Heart rate
- D. Temperature
- E. Dyspareunia
- F. Condom usage
Correct Answer: A,B,D,E,F
Rationale: The correct answers to report to the provider are A, B, D, E, and F. A: Abdominal assessment is crucial to identify any potential underlying issues. B: Vaginal discharge in an adolescent may indicate infection or hormonal imbalance. D: Temperature abnormalities could signal infection. E: Dyspareunia (pain during intercourse) may indicate reproductive health concerns. F: Condom usage is important for safe sex practices. Choices C and G are not specifically related to the adolescent's care needs and do not require immediate reporting.
A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?
- A. Oligohydramnios.
- B. Hyperemesis gravidarum.
- C. Leukorrhea.
- D. Periodic tingling of the fingers.
Correct Answer: A
Rationale: The correct answer is A: Oligohydramnios. Electronic fetal monitoring is used to assess the well-being of the fetus during pregnancy, labor, and delivery. Oligohydramnios refers to a low level of amniotic fluid, which can indicate fetal distress or compromise. Monitoring the fetal heart rate patterns using electronic fetal monitoring in this case can help detect any abnormalities and guide appropriate interventions to optimize fetal outcomes.
Incorrect choices:
B: Hyperemesis gravidarum - This is severe nausea and vomiting in pregnancy, not a direct indication for fetal monitoring.
C: Leukorrhea - This is a common vaginal discharge in pregnancy, not a direct indication for fetal monitoring.
D: Periodic tingling of the fingers - This is not related to fetal assessment and is more likely a symptom of a different issue, such as nerve compression.
A nurse is providing teaching to a client who is breastfeeding and experiencing engorgement. Which of the following recommendations should the nurse include?
- A. Apply warm compresses on the breasts before feedings
- B. Allow the infant to nurse on one breast per feeding.
- C. Take aspirin to reduce pain and swelling.
- D. Wear a tight-fitting underwire bra.
Correct Answer: A
Rationale: The correct answer is A: Apply warm compresses on the breasts before feedings. Warm compresses help to promote milk flow and relieve engorgement by increasing blood flow to the area. This can make it easier for the baby to latch and feed effectively. It is important to address engorgement promptly to prevent complications such as blocked ducts or mastitis.
Option B is incorrect because allowing the infant to nurse on one breast per feeding may not fully empty the breasts, leading to further engorgement. Option C is incorrect because aspirin is not recommended during breastfeeding due to potential risks to the infant. Option D is incorrect because wearing a tight-fitting underwire bra can constrict the breasts and worsen engorgement.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. Early decelerations in the PHR.
- C. Temperature 37.4° C (99 3* F).
- D. PHR baseline 170/min.
Correct Answer: D
Rationale: The correct answer is D: PHR baseline 170/min. A baseline fetal heart rate of 170/min is considered tachycardia and may indicate fetal distress, requiring immediate attention. This finding can be indicative of fetal hypoxia or other complications. The nurse should report this to the provider promptly for further evaluation and intervention.
Contractions lasting 80 seconds (choice A) are within the normal range for active labor and do not necessarily require immediate reporting.
Early decelerations in the PHR (choice B) are benign and typically not a cause for concern unless they are persistent or associated with other abnormal findings.
A temperature of 37.4°C (99.3°F) (choice C) is within normal limits and does not require immediate reporting unless it continues to rise significantly.
In summary, the correct answer is D because a baseline fetal heart rate of 170/min is abnormal and potentially indicative of fetal distress, requiring immediate provider notification.
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: The correct answer is D. The nurse should inform the client that staff members caring for the newborn will be wearing a photo identification badge as a safety measure. This ensures that only authorized personnel are handling the baby, reducing the risk of abduction or unauthorized access. It also helps the client easily identify legitimate staff members.
Choice A is incorrect because it is not recommended for nurses to carry newborns to the nursery for procedures due to infection control policies. Choice B is irrelevant to promoting the security and safety of the newborn. Choice C is incorrect as bed-sharing with a newborn in the hospital setting is not safe due to the risk of suffocation and Sudden Infant Death Syndrome (SIDS).