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A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
- A. Monitor blood glucose levels.
- B. Monitor intake and output.
- C. Monitor weight.
- D. Monitor axillary temperature.
Correct Answer: A
Rationale: Correct Answer: A - Monitor blood glucose levels.
Rationale: Small for gestational age (SGA) newborns are at risk for hypoglycemia due to decreased glycogen stores. Monitoring blood glucose levels is crucial to detect and manage hypoglycemia promptly. This intervention ensures early intervention to prevent complications.
Incorrect Choices:
B: Monitoring intake and output is important for overall assessment but not specific to SGA newborns.
C: Monitoring weight is important for growth assessment but does not directly address the immediate risk of hypoglycemia in SGA newborns.
D: Monitoring axillary temperature is important for assessing newborn's thermoregulation but does not address the specific risk of hypoglycemia in SGA newborns.
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A nurse in a provider’s office is caring for a client who is at 36 weeks of gestation and scheduled for an amniocentesis. The client asks why she is having an ultrasound prior to the procedure. Which of the following is an appropriate response by the nurse?
- A. It assists in identifying the location of the placenta and fetus.
- B. It is useful for estimating fetal age.
- C. This is a screening tool for spina bifida.
- D. This will determine if there is more than one fetus.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Prior to amniocentesis, an ultrasound is done to identify the location of the placenta and fetus. This is crucial to ensure the safety of the procedure. It helps in determining the best site for needle insertion to avoid harming the fetus or placenta. Additionally, it allows for visualization of any abnormalities that could affect the amniocentesis procedure.
Summary of other choices:
B: Estimating fetal age is not the primary purpose of the ultrasound before amniocentesis.
C: Screening for spina bifida is usually done through other specific tests, not the ultrasound before amniocentesis.
D: Determining if there is more than one fetus is not the main goal of the ultrasound before amniocentesis.
A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?
- A. Accidental lacerations
- B. Respiratory distress
- C. Hypothermia
- D. Acrocyanosis
Correct Answer: B
Rationale: The correct answer is B: Respiratory distress. The nurse's priority is to ensure the newborn's ability to breathe effectively. Respiratory distress is common after cesarean delivery due to fluid in the lungs. Addressing this promptly is critical to prevent complications. Accidental lacerations (A) are important but not immediately life-threatening. Hypothermia (C) can be addressed after ensuring the newborn's respiratory status. Acrocyanosis (D) is a common finding in newborns and not an urgent concern.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Select all that apply:
- A. Antibiotic ointment to both eyes
- B. Hepatitis B immunization
- C. Lidocaine gel to the umbilical stump
- D. Haemophilus influenzae type b immunization
- E. Vitamin K injection
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A: Antibiotic ointment to both eyes is given to prevent neonatal conjunctivitis. B: Hepatitis B immunization is crucial for newborns to prevent Hepatitis B infection. E: Vitamin K injection is given to prevent hemorrhagic disease of the newborn. C: Lidocaine gel to the umbilical stump is not a standard practice and can cause local irritation. D: Haemophilus influenzae type b immunization is typically given later in infancy, not immediately after birth.