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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: The correct answer is A because laying the newborn across the lap and gently swaying helps create a soothing and comforting environment for the baby. This position mimics the closeness and security of being held, promoting bonding and emotional connection between the guardian and the newborn. It also aids in digestion and reduces the risk of choking. Placing the newborn in the crib in a prone position (B) is unsafe as it increases the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may introduce unnecessary calories and disrupt feeding patterns. Preparing a bottle with rice cereal (D) can pose a choking hazard and is not recommended for newborns.
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A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Ensuring that the parent's identification band number matches the newborn's identification band number is crucial for accurate identification. This step confirms that the parent is indeed the rightful guardian of the newborn, preventing mix-ups and ensuring the newborn's safety. Verifying the parent's identity through their name and date of birth (Option B) is helpful but not as reliable as matching identification band numbers. Checking the newborn's security tag number (Option C) is important for hospital security but does not directly verify the parent's identity. Matching the newborn's date and time of birth to the information in the parent's medical record (Option D) is not as specific and reliable as matching identification band numbers.
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 indicated for assessing fetal well-being in pregnancies with conditions that may compromise fetal oxygenation, such as oligohydramnios. Oligohydramnios is a condition where there is an insufficient amount of amniotic fluid around the fetus, which can lead to fetal distress. Electronic fetal monitoring helps track the fetal heart rate and uterine contractions to detect signs of distress. Hyperemesis gravidarum (B), leukorrhea (C), and periodic tingling of the fingers (D) are not indications for fetal monitoring as they do not directly impact fetal well-being.
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: The correct answer is C. Removing all clothing from the newborn except the diaper during phototherapy is essential as it helps maximize the skin surface area exposed to the light, thus enhancing the effectiveness of the treatment. This allows for better absorption of the light by the skin, aiding in the breakdown of bilirubin.
A: Feeding the newborn water every 4 hours is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion to the newborn's skin may interfere with the effectiveness of phototherapy and should be avoided.
D: Discontinuing therapy if a rash develops is not advisable, as a rash is a common side effect of phototherapy and does not necessarily require therapy cessation.
A nurse is caring for a newborn who is 70 hr old. Which of the following findings should the nurse report to the provider? (Select all that apply.)
- A. Respiratory findings
- B. Temperature
- C. Oxygen Saturation
- D. Central nervous system findings
- E. Gastrointestinal findings
Correct Answer: A, D, E
Rationale: The correct answers are A (Respiratory findings), D (Central nervous system findings), and E (Gastrointestinal findings). These are crucial areas to monitor in a newborn to ensure their well-being. Respiratory findings are important as newborns are prone to respiratory distress. Central nervous system findings are vital for assessing neurological status. Gastrointestinal findings are necessary to monitor feeding tolerance and bowel movements. Temperature, oxygen saturation, and other choices are also important but may not be as critical in this case. It is essential to focus on the key areas that can indicate potential issues and require immediate attention.
A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?
- A. Depression.
- B. Polyuria.
- C. Hypotension.
- D. Urticaria.
Correct Answer: A
Rationale: The correct answer is A: Depression. Combined oral contraceptives can lead to mood changes, including depression, as a potential adverse effect due to hormonal fluctuations. This is important for the nurse to include in teaching to monitor and address any mental health concerns. Polyuria (increased urination) is not a common adverse effect of combined oral contraceptives. Hypotension (low blood pressure) is not typically associated with this medication. Urticaria (hives) is more commonly seen with allergic reactions rather than as a side effect of oral contraceptives.