Nokea
A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?
- A. Preterm newborns have a smaller body surface area than normal newborns.
- B. The added brown fat layer in a preterm newborn reduces his ability to generate heat.
- C. Preterm newborns lack adequate temperature control mechanisms.
- D. The heat in the incubator rapidly dries the sweat of preterm newborns.
Correct Answer: C
Rationale: The correct answer is C because preterm newborns lack adequate temperature control mechanisms. Preterm infants have underdeveloped regulatory systems, making them vulnerable to heat loss or overheating. Maintaining a neutral thermal environment in an incubator helps prevent fluctuations in body temperature.
Choice A is incorrect because surface area alone does not explain the need for a neutral thermal environment. Choice B is incorrect as brown fat actually helps generate heat in newborns. Choice D is incorrect as drying sweat is not the primary reason for using an incubator in preterm newborns.
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A woman at 38 weeks of gestation is admitted in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?
- A. Recheck the client's temperature in 4 hours.
- B. Administer glucocorticoids intramuscularly.
- C. Assess the odor of the amniotic fluid.
- D. Prepare the client for emergency cesarean section.
Correct Answer: C
Rationale: The correct answer is C: Assess the odor of the amniotic fluid. This is the appropriate nursing action because the woman is at risk for chorioamnionitis due to the elevated temperature and ruptured membranes. Assessing the odor of the amniotic fluid can help in identifying signs of infection, as foul-smelling amniotic fluid may indicate chorioamnionitis. This can guide further interventions and management, such as initiating antibiotics.
Choice A is incorrect as waiting 4 hours to recheck the temperature can delay necessary interventions for potential infection. Choice B is also incorrect as administering glucocorticoids is not the immediate priority in this situation. Choice D is incorrect as preparing for an emergency cesarean section is not warranted solely based on the client's temperature and ruptured membranes without further assessment for infection.
A healthcare provider is preparing to administer vitamin K by IM injection to a newborn. The medication should be administered into which of the following muscles?
- A. Vastus lateralis
- B. Ventrogluteal
- C. Dorsogluteal
- D. Deltoid
Correct Answer: A
Rationale: The correct answer is A: Vastus lateralis. This muscle is the preferred site for IM injections in newborns due to its large muscle mass and minimal risk of damage to nerves and blood vessels. Administering vitamin K in the vastus lateralis ensures proper absorption and distribution of the medication. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of sciatic nerve damage and limited muscle mass. The deltoid muscle is typically used for older children and adults, not newborns.
During an assessment of a newborn following a vacuum-assisted delivery, which of the following findings should the healthcare provider be informed about?
- A. Poor sucking
- B. Blue discoloration of the hands and feet
- C. Soft, edematous area on the scalp
- D. Facial edema
Correct Answer: A
Rationale: The correct answer is A: Poor sucking. This finding is concerning as it may indicate potential issues with feeding and nutrition in the newborn, which can lead to complications. Poor sucking can be a sign of various underlying problems that require prompt intervention. Blue discoloration of the hands and feet (choice B) is likely due to peripheral cyanosis, which is common in newborns and often resolves on its own. Soft, edematous area on the scalp (choice C) is a common finding in newborns after vacuum-assisted delivery and typically resolves without intervention. Facial edema (choice D) is also a common finding in newborns after delivery and typically resolves on its own.
A client who underwent an amniotomy is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?
- A. Maintain the client in the lithotomy position.
- B. Perform vaginal examinations frequently.
- C. Remind the client to bear down with each contraction.
- D. Encourage the client to empty her bladder every 2 hours.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to empty her bladder every 2 hours. This is important to prevent bladder distention, which can impede fetal descent and progression of labor. A: Maintaining the client in the lithotomy position is unnecessary and may be uncomfortable. B: Performing frequent vaginal examinations increases the risk of infection and should be minimized. C: Reminding the client to bear down with each contraction is not appropriate during the active phase of the first stage of labor as it can lead to exhaustion and prolonged labor.
A client who is postpartum received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in blood pressure
- B. Fundus firm to palpation
- C. Increase in lochia
- D. Report of absent breast pain
Correct Answer: B
Rationale: The correct answer is B: Fundus firm to palpation. Methylergonovine is a medication used to promote uterine contraction, which helps the uterus return to its pre-pregnancy size and prevent postpartum hemorrhage. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which is the desired outcome of giving methylergonovine.
A: Increase in blood pressure is not a direct indicator of the medication's effectiveness in this context.
C: Increase in lochia may be a sign of uterine involution but does not directly correlate with the effectiveness of methylergonovine.
D: Reporting of absent breast pain is not a specific indicator of the medication's effectiveness related to uterine contraction.