Nokea
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
- A. Apply a thin layer lotion to the newborn's skin every 8 hours
- B. Dress the newborn in a thin layer of clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.
Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.
In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.
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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.
The nurse is teaching a client and her partner about the technique of counter pressure during labor. Which of the following statements by the nurse is appropriate?
- A. Your partner will apply upward pressure on your lower abdomen between contractions
- B. Your partner will apply continuous firm pressure between your thumb and index finger
- C. Your partner will apply pressure to the top of your uterus during contractions
- D. Your partner will apply steady pressure with a tennis ball to your lower back
Correct Answer: D
Rationale: The correct answer is D because counter pressure is typically applied to the lower back to help alleviate back pain during labor contractions. This technique can help relieve discomfort by stimulating pressure receptors and distracting from the pain of contractions. Choice A is incorrect as upward pressure on the lower abdomen is not the standard technique for counter pressure. Choice B is incorrect as applying pressure between the thumb and index finger is not relevant to counter pressure. Choice C is incorrect as pressure should be applied to the lower back, not the top of the uterus, during contractions.
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 any procedure that involves contact with bodily fluids or potentially infectious material, such as blood or bodily secretions. Umbilical cord care may involve cleaning the area, which can have potential exposure to bodily fluids. The other choices (A, B, C) do not involve direct contact with bodily fluids or infectious material, so gloves are not necessary for those procedures. It is important to maintain infection control practices to prevent the spread of infections in the healthcare setting.
A nurse is providing discharge teaching to a new parent about car seat safety. Which of the following statements by the parent indicates an understanding of the teaching?
- A. “I should position my baby’s car seat at a 45-degree angle in the car.”
- B. “I should place the car seat rear facing until my baby is 12 months old.”
- C. “I should place the harness snugly in a slot above my baby’s shoulders.”
- D. “I should position the retainer clip at the top of my baby’s abdomen.”
Correct Answer: A
Rationale: The correct answer is A because positioning the baby's car seat at a 45-degree angle helps prevent the baby's head from slumping forward, ensuring proper airway and breathing. Placing the car seat rear facing until 12 months old is recommended for optimal safety. Option C is incorrect as the harness should be at or below the baby's shoulders. Option D is incorrect as the retainer clip should be positioned at armpit level for proper safety.
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.