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A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn’s skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: Removing all clothing except the diaper ensures maximum skin exposure to the phototherapy lights, which is essential for effective treatment of hyperbilirubinemia.
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What is the function of the placenta during pregnancy?
- A. To protect the fetus from infection
- B. To remove waste products from the fetus
- C. To facilitate nutrient and gas exchange between the mother and fetus
- D. All of the above
Correct Answer: D
Rationale: The placenta protects the fetus, removes waste, and facilitates nutrient and gas exchange.
Which stage of labor is characterized by the period between the end of the third stage and the mother's recovery from delivery?
- A. First stage
- B. Second stage
- C. Third stage
- D. Fourth stage
Correct Answer: D
Rationale: The correct answer is D: Fourth stage. The fourth stage of labor is the period immediately following the delivery of the baby and placenta, lasting up to 2 hours. This stage is crucial for monitoring the mother's vital signs and ensuring she recovers from the delivery process. It is characterized by postpartum uterine contractions, monitoring for excessive bleeding, and observing for signs of maternal complications. The first stage refers to the onset of labor until full dilation, the second stage is active labor and delivery of the baby, and the third stage is the delivery of the placenta. Therefore, the fourth stage is specifically focused on the mother's recovery from delivery, making it the correct choice.
Which of the following is a potential complication of a retained placenta?
- A. Preeclampsia
- B. Postpartum hemorrhage
- C. Gestational diabetes
- D. All of the above
Correct Answer: B
Rationale: The correct answer is B: Postpartum hemorrhage. A retained placenta can lead to postpartum hemorrhage due to incomplete delivery of the placenta, causing excessive bleeding. Preeclampsia and gestational diabetes are not directly related to a retained placenta. Therefore, the correct answer is B.
Which of the following is a potential complication of a preterm infant?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Hyperbilirubinemia
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D: All of the above. Preterm infants are at increased risk for various complications due to their immature organ systems. Hypoglycemia can occur due to limited glycogen stores. Respiratory distress syndrome results from insufficient surfactant production in underdeveloped lungs. Hyperbilirubinemia is common as the liver may not efficiently process bilirubin. Choosing D is correct as all these complications can affect preterm infants. Options A, B, and C are incorrect as they individually address only one potential complication, whereas D encompasses all possibilities.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: Laying the newborn across the lap and gently swaying is a positive parenting behavior that can help soothe the newborn and promote bonding.