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A nurse is caring for four newborns. Which of the following newborns should the nurse assess first?
- A. newborn who has nasal flaring
- B. newborn who has subconjunctival hemorrhage of the left eye
- C. A newborn who has overlapping suture lines
- D. A newborn who has not rust-stained urine
Correct Answer: A
Rationale: The correct answer is A: newborn who has nasal flaring. Nasal flaring indicates respiratory distress, which is a priority concern in newborns as it can lead to hypoxia. The nurse should assess this newborn first to ensure adequate oxygenation.
B: Subconjunctival hemorrhage is common and not an urgent issue.
C: Overlapping suture lines are normal in newborns and do not require immediate attention.
D: Not passing rust-stained urine could indicate a metabolic issue but is not as urgent as respiratory distress.
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A charge nurse is teaching a group of staff nurses about fetal monitoring during labor. Which of the following findings should the charge nurse instruct the staff members to report to the provider?
- A. Contraction durations of 95 to 100 seconds
- B. Contraction frequency of 2 to 3 min apart
- C. Absent early deceleration of fetal heart rate
- D. Fetal heart rate is 140/min
Correct Answer: A
Rationale: The correct answer is A: Contraction durations of 95 to 100 seconds. This is an abnormal finding as typical contraction durations should be around 60-90 seconds. Prolonged contractions can lead to decreased fetal oxygenation and distress. Choice B is incorrect as contractions 2-3 minutes apart are within the normal range. Choice C is incorrect as absent early deceleration is a reassuring sign of fetal well-being. Choice D is incorrect as a fetal heart rate of 140/min is within the normal range of 110-160/min.
A client who is 16 weeks of gestation asks the nurse how to prepare her toddler for a younger sibling.
- A. You should hold your newborn in your arms when you introduce him to your toddler
- B. You should move your toddler out of her crib 2 weeks prior to your due date
- C. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born
- D. You should place your toddler in timeout if she exhibits regressive behavior after the baby is born
Correct Answer: B
Rationale: The correct answer is B because moving the toddler out of the crib before the baby arrives allows the toddler time to adjust to the change without associating it directly with the baby's arrival. Holding the newborn in your arms (A) may make the toddler feel left out. Placing the toddler in timeout (C, D) for regressive behavior can create negative associations with the new sibling.
A nurse in a provider’s office is assessing a client at her first antepartum visit. The client states that the first day of her last menstrual period was March 8. Use Negele’s rule to calculate the estimated date of delivery. (Use the MMDD format with four numerals and no spaces or punctuation.)
- A. December 15
- B. October 30
- C. January 15
- D. Nov 30
Correct Answer: A
Rationale: To calculate the estimated due date using Negele's rule, we add 7 days to the first day of the last menstrual period, subtract 3 months, and then add a year. March 8 + 7 days = March 15. Subtracting 3 months gives us December 15. Adding a year gives the estimated due date as December 15. This is the correct answer as it follows the standard calculation method. Other choices are incorrect as they do not follow the correct formula or have errors in calculation.
A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
A nurse is planning care immediately following birth for a newborn who has myelomeningocele that is leaking cerebrospinal fluid.
- A. Administer broad-spectrum antibiotics
- B. Cleans the site with povidone-iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A. Administering broad-spectrum antibiotics is crucial to prevent infection since the exposed spinal cord increases the risk. Antibiotics help reduce the risk of meningitis and sepsis. Choice B is incorrect as povidone-iodine can be irritating to the sensitive skin around the defect. Choice C is incorrect as monitoring rectal temperature is not directly related to the immediate care needed for a myelomeningocele. Choice D is incorrect because surgical closure should be done as soon as possible to prevent further complications.