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A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn’s visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: The correct answer is D: Swaddle the newborn in a flexed position. This intervention helps provide comfort and security to the newborn, which can help reduce symptoms of neonatal abstinence syndrome. Swaddling in a flexed position mimics the womb environment, promoting relaxation and reducing irritability.
A: Increasing visual stimulation can overwhelm the newborn and exacerbate symptoms.
B: Weighing the newborn every other day is not directly related to managing neonatal abstinence syndrome.
C: Discouraging parental interaction can hinder bonding and support, which are crucial for the newborn's well-being.
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A nurse is planning to teach a group of clients who are about breastfeeding after returning to work. Which of the following infection should the nurse include in the teaching?
- A. “Thawed breast milk can be refrigerated for up to 72 hours.”
- B. “Breast milk can be stored in a deep freezer for 12 months.”
- C. Breast milk can be stored at room temperature for up to 12 hours.”
- D. “Thawed breast milk that is unused can be refrozen.”
Correct Answer: B
Rationale: The correct answer is B: “Breast milk can be stored in a deep freezer for 12 months.” This is correct because breast milk can indeed be stored in a deep freezer for up to 12 months, maintaining its quality and safety. Deep freezing helps preserve the nutrients in breast milk for a longer period compared to standard refrigeration.
Choice A is incorrect because thawed breast milk should be used within 24 hours if stored in the refrigerator, not 72 hours. Choice C is incorrect because breast milk can only be stored at room temperature for up to 4 hours. Choice D is incorrect because thawed breast milk should not be refrozen; it should be used within 24 hours.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn’s temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. This is because lotions or ointments can interfere with the effectiveness of phototherapy by blocking the light from reaching the skin. Dressing the newborn in lightweight clothing (Choice A) is important to maximize skin exposure to the light. Keeping the newborn supine throughout treatment (Choice C) is not directly related to the effectiveness of phototherapy. Measuring the newborn's temperature every 8 hours (Choice D) is important but not specifically related to phototherapy.
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.
A nurse is caring for an infant who has signs of neonatal abstinence syndrome. Which of the following actions should the nurse take?
- A. Provide a stimulating environment
- B. Monitor blood glucose level every hr.
- C. Initiate seizure precautions.
- D. Place the infants on his back with legs extended.
Correct Answer: B
Rationale: The correct answer is B: Monitor blood glucose level every hr. Neonatal abstinence syndrome can lead to hypoglycemia in infants. Monitoring blood glucose levels every hour allows for early detection and intervention. Providing a stimulating environment (A) can worsen symptoms. Initiating seizure precautions (C) is not necessary unless seizures are present. Placing the infant on his back with legs extended (D) does not address the specific issue of neonatal abstinence syndrome.
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.