Nokea
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap. Which of the following actions should the nurse include?
- A. Apply a thin layer lotion to the newborn skin every 8 hours
- B. Trust in you born in a thin layer 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. This is crucial during phototherapy to protect the newborn's eyes from potential damage caused by the bright lights. Newborns undergoing phototherapy should have their eyes shielded with protective eye coverings to prevent eye damage. Choice A is incorrect as lotion can intensify the effects of phototherapy. Choice B is incorrect as the newborn should be undressed to maximize skin exposure. Choice D is incorrect as glucose water is not indicated for phototherapy and may interfere with treatment.
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A nurse is using Niagele9s rule to calculate the expected delivery date of a client who reports the first day of the last menstrual cycle was July 28th. Which of the following dates should the nurse document as a client expected delivery date? 07/28
- A. April 21st
- B. April 4th
- C. May 5th
- D. May 21st
Correct Answer: C
Rationale: The correct answer is C: May 5th. To calculate the expected delivery date using Naegele's rule, add 7 days to the first day of the last menstrual period (July 28th), then subtract 3 months, and add 1 year. July 28th + 7 days = August 4th. Subtract 3 months = May 4th. Add 1 year = May 5th. Choice A is incorrect as it is too early. Choice B is incorrect as it is also too early. Choice D is incorrect as it is too late.
A nurse is caring for a newborn Boys 6 hours old and has a bedside glucose meter reading of 65 mg / DL. The New Orleans mother has Type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Administer 50 mL of dextrose solution IV
- B. Obtain a blood sample of serum glucose level
- C. Reassess the blood glucose level prior to the next feeding
- D. Feed the newborn immediately
Correct Answer: D
Rationale: The correct answer is D: Feed the newborn immediately. In this scenario, the newborn's blood glucose level is 65 mg/dL, which is considered low. Given that the mother has Type 2 diabetes, the baby is at risk for hypoglycemia due to maternal hyperglycemia during pregnancy. Feeding the newborn immediately will help increase their blood glucose levels. IV dextrose solution administration (choice A) is not necessary at this time as the baby can be orally fed. Obtaining a blood sample for serum glucose level (choice B) can be done later after feeding to confirm improvement. Reassessing blood glucose prior to the next feeding (choice C) delays necessary intervention. The baby must be fed promptly to prevent further hypoglycemia.
A nurse is observing an adolescent client who is offering her newborn a bottle while he is laying in the bassinet. When the nurse offers to pick the newborn up and place them in the client's arms, the mother States < No, the baby is too tired to be held=. Which of the following actions should the nurse take?
- A. Insist that the mother pick up the newborn to feed him
- B. Demonstrate how to hold a newborn and allow the client to practice
- C. Persuade the client to breastfeed the newborn to promote bonding
- D. Offer to take the newborn to the nursery to finish his feeding
Correct Answer: B
Rationale: The correct answer is B: Demonstrate how to hold a newborn and allow the client to practice. This response promotes education and empowerment by showing the client the proper way to hold and feed the newborn, fostering a supportive and educational environment. Insisting on the mother picking up the newborn (choice A) disregards the mother's wishes and may lead to conflict. Persuading the client to breastfeed (choice C) may not be appropriate if the client has chosen bottle-feeding. Taking the newborn to the nursery (choice D) does not address the client's desire to feed her baby.
A nurse is caring for a client who has preterm labor and receiving magnesium sulfate by continuous IV infusion. Which of the following laboratory values should the nurse review during tocolytic therapy?
- A. Indirect Coombs test
- B. Liver enzymes
- C. Uric acid level
- D. Serum medication level
Correct Answer: D
Rationale: The correct answer is D: Serum medication level. The nurse should review this value during tocolytic therapy with magnesium sulfate because it is crucial to monitor the therapeutic range of magnesium to prevent toxicity. Monitoring serum levels helps ensure the medication is effective yet safe for the client and the baby.
A: Indirect Coombs test is used to detect antibodies on the surface of red blood cells, not relevant in this scenario.
B: Liver enzymes may be affected by magnesium sulfate but are not directly related to monitoring the medication's therapeutic effect.
C: Uric acid level is not typically monitored during tocolytic therapy with magnesium sulfate.
E, F, G: Irrelevant options.
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions Should the nurse include in the plan of care?
- 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 action is crucial to reduce the risk of HIV transmission from the mother to the newborn. By bathing the newborn before skin-to-skin contact, the nurse can remove any potential HIV-infected fluids from the baby's skin, reducing the risk of transmission. This step helps to protect the newborn while still allowing for important bonding through skin-to-skin contact after bathing.
Choice A is incorrect as the use of a fetal scalp electrode during labor and delivery is unrelated to preventing HIV transmission from mother to newborn. Choice C is incorrect as stopping antiretroviral medication can significantly increase the risk of HIV transmission to the newborn. Choice D is incorrect as administering pneumococcal immunization is important but not within 4 hours following birth in the context of preventing HIV transmission.