Nokea
A nurse is planning care for a client who is pregnant and has HIV.
- A. Use a fetal scalp electrode during labor and delivery
- B. Bathe the newborn before initiating skin-to-skin contact
- C. Instruct the client to stop taking the antiretroviral medication at 32 weeks of gestation
- D. Administer pneumococcal immunization to the newborn within 4 hours following birth
Correct Answer: B
Rationale: The correct answer is B: Bathe the newborn before initiating skin-to-skin contact. This is because bathing the newborn before skin-to-skin contact helps reduce the risk of HIV transmission from mother to baby. HIV can be present in maternal blood and other fluids, and washing the newborn can decrease the viral load on the baby's skin. Initiating skin-to-skin contact without bathing first may increase the risk of transmission.
Choice A is incorrect because using a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to baby. Choice C is incorrect as stopping antiretroviral medication can be harmful to both the mother and the baby's health. Choice D is incorrect as pneumococcal immunization is not recommended within 4 hours following birth and is not directly related to HIV transmission prevention.
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A nurse is providing teaching to the parents of a newborn about the plastibell circumcision technique.
- A. The plastibell will be removed 4 hours after the procedure
- B. Notify the provider if the end of the penis appears dark red
- C. Make sure the newborn's diaper is snug
- D. Yellow exudate will form at the surgical site in 24 hours
Correct Answer: B
Rationale: The correct answer is B: Notify the provider if the end of the penis appears dark red. This is because dark red coloration at the end of the penis could indicate infection or compromised blood flow, requiring immediate medical attention. Choice A is incorrect as the plastibell is typically left in place for about a week, not 4 hours. Choice C is incorrect as a snug diaper can cause discomfort and hinder healing. Choice D is incorrect because yellow exudate is a normal part of the healing process, usually appearing within 24-48 hours post-circumcision.
A nurse is caring for a client who has a complete uterine rupture. Which of the following findings should the nurse expect?
- A. Early fetal heart rate decelerations
- B. Hypotension
- C. Painless, dark red vaginal bleeding
- D. bounding peripheral pulses
Correct Answer: B
Rationale: The correct answer is B: Hypotension. A complete uterine rupture is a serious complication where the uterine wall tears completely, leading to massive internal bleeding. This can result in hypotension due to blood loss. Early fetal heart rate decelerations (choice A) are not indicative of uterine rupture. Painless, dark red vaginal bleeding (choice C) is more commonly associated with placental abruption. Bounding peripheral pulses (choice D) are not a typical finding in uterine rupture.
A nurse is providing discharge teaching to a postpartum client about caring for her five-day-old male newborn at home.
- A. Retract the foreskin to clean your baby's penis during each bath
- B. Use triple antibiotic ointment on your baby's umbilical cord twice per day
- C. Swaddle your baby tightly with legs extended before laying him down to sleep
- D. Notify your baby's pediatrician if he urinates less than 6 times per day
Correct Answer: D
Rationale: The correct answer is D: Notify your baby's pediatrician if he urinates less than 6 times per day. This is important because adequate urine output is a sign of good hydration and kidney function in newborns. Notifying the pediatrician if the baby urinates less than 6 times a day can help identify any potential issues early on.
Choice A is incorrect because retracting the foreskin to clean the baby's penis is not recommended as it can lead to infections.
Choice B is incorrect because using triple antibiotic ointment on the umbilical cord is not necessary and can actually delay healing.
Choice C is incorrect because swaddling the baby tightly with legs extended can increase the risk of hip dysplasia.
Overall, it is important to focus on monitoring the baby's urine output and notifying the pediatrician if there are any concerns.
A nurse is assessing a newborn who was born Post term. Which of the following findings should the nurse expect?
- A. Nails extending over tips of fingers
- B. Large deposits of subcutaneous fat
- C. Pale, translucent skin
- D. Thin covering of fine hair on shoulders and back
Correct Answer: A
Rationale: The correct answer is A - Nails extending over tips of fingers. Post-term newborns may have longer nails due to prolonged exposure in utero. This is because the baby had more time for nail growth compared to a term baby. Nails extending over the tips of the fingers is a common finding in post-term newborns. The other choices are incorrect because large deposits of subcutaneous fat (B) are more common in term or postmature infants, pale, translucent skin (C) is more characteristic of preterm infants, and a thin covering of fine hair on shoulders and back (D) is typical of lanugo, which is usually shed before birth or shortly after for post-term infants.
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.