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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 can help soothe the baby by providing comfort and closeness. This position mimics the feeling of being held in the womb and the swaying motion can be calming. Placing the newborn in the crib in a prone position (B) is not recommended due to the risk of sudden infant death syndrome. Offering a pacifier dipped in formula (C) may lead to overfeeding and potential nipple confusion. Preparing a bottle of formula mixed with rice cereal (D) is not recommended for newborns as their digestive systems are not ready for solids.
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A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A: Minimal arm recoil. In premature newborns born at 26 weeks of gestation, they typically exhibit minimal arm recoil due to their immature neuromuscular development. This is a key characteristic assessed in the New Ballard Score to determine the gestational age of the newborn. Choices B, C, and D are incorrect as they do not align with the expected findings in a premature newborn at 26 weeks of gestation. Popliteal angle of 90° (Choice B) is more typical in a term newborn. Creases over the entire foot sole (Choice C) are also more common in term newborns. Raised areolas with 3 to 4 mm buds (Choice D) are indicative of a more mature newborn and not typically seen in a premature newborn at 26 weeks of gestation.
A nurse is caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?
- A. Passive descent
- B. Active
- C. Early
- D. Descent
Correct Answer: B
Rationale: The correct answer is B: Active phase. At 9 cm dilation, the client is in the active phase of the first stage of labor. This phase is characterized by more rapid cervical dilation (6-10 cm) and increased contractions with shorter intervals. The client's symptoms align with this phase as they are experiencing strong contractions close together, along with increased rectal pressure indicating descent of the fetus. Other choices are incorrect as: A (Passive descent) occurs during the second stage of labor; C (Early phase) is typically before 6 cm dilation; D (Descent) is not a recognized phase of labor.
A nurse is caring for a newborn who is 70 hr old. Exhibit 1
Medical History
Newborn delivered by repeat cesarean birth at 40 weeks of gestation.
Birth weight 3,515 g (7 lb 12 oz)
Apgar scores 8 at 1 min and 9 at 5 min
Maternal history of methadone use during pregnancy.
Exhibit 2
Vital Signs
0700:
Heart rate 156/min
Respiratory rate 58/min
Temperature 37.2° C (98.9° F)
Oxygen saturation 98% on room air
1100:
Heart rate 160/min
Respiratory rate 60/min
Temperature 37.3° C (99.2° F)
Oxygen saturation 96% on room air
Exhibit 3
Physical Examination
1100:
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but
breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several
loose stools today.
Exhibit 4
Diagnostic Results
Maternal urine toxicology screen positive for opiates (negative)
Newborn urine toxicology screen positive for opiates (negative)
Which of the following findings should the nurse report to the provider? Select all that apply.
- A. Respiratory findings
- B. Oxygen saturation
- C. Central nervous system findings
- D. Gastrointestinal findings
Correct Answer: C,D
Rationale: The nurse should report central nervous system (CNS) and gastrointestinal (GI) findings to the provider as they can indicate potential serious issues. CNS findings like altered mental status or neurological deficits may signal neurological problems. GI findings such as abdominal pain or bleeding may indicate gastrointestinal issues that require immediate attention. Respiratory findings (choice A) and oxygen saturation (choice B) are important but may not always require immediate reporting unless they are significantly abnormal. The other choices are not directly related to urgent medical concerns. Reporting CNS and GI findings ensures prompt evaluation and appropriate intervention.
A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?
- A. Administer aspirin for pain.
- B. Maintain the client on bed rest.
- C. Massage the affected leg every 12 hr.
- D. Apply cold compresses to the affected calf.
Correct Answer: B
Rationale: The correct answer is B: Maintain the client on bed rest. In a client receiving heparin for thrombophlebitis, bed rest is essential to prevent dislodgment of the clot and avoid further complications. Moving around can increase the risk of embolism. Administering aspirin (choice A) is not recommended as it can increase the risk of bleeding with heparin. Massaging the affected leg (choice C) can dislodge the clot leading to embolism. Applying cold compresses (choice D) can also increase the risk of dislodging the clot. The key is to promote circulation without dislodging the clot, which is achieved by keeping the client on bed rest.
A nurse is caring for a newborn.
Exhibit1
Vital Signs
8 hr of age:
Temperature: 37.1° C (98.8° F) Axillary
Pulse rate: 132/min
Respiratory rate: 52/min
36 hr of age:
Temperature: 36.1° C (97" F) Axillary
Pulse rate: 160/min
Respiratory rate: 78/min”
For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis.
- A. Ecchymotic caput Succedaneum.
- B. Decreased temperature.
- C. Lethargy.
- D. Poor feeding.
- E. Respiratory distress.
- F. Yellow sclera and oral mucosa.
Correct Answer: B, C, D, E, F
Rationale: The correct answer is . Decreased temperature (B) can indicate hypoglycemia, sepsis, or hypothermia. Lethargy (C) can be a sign of hypoglycemia, sepsis, or other serious conditions. Poor feeding (D) is common in hypoglycemia, sepsis, and other illnesses. Respiratory distress (E) is a red flag for sepsis. Yellow sclera and oral mucosa (F) suggest hyperbilirubinemia. Ecchymotic caput Succedaneum (A) is not typically associated with these conditions.