Nokea
A nurse is planning care immediately following birth for a newborn who has Myelomeningocele that is cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?
- A. Administer broad-spectrum antibiotics
- B. Cleanse the site with Povidone iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A: Administer broad-spectrum antibiotics. This is crucial in preventing infection in a newborn with myelomeningocele where the spinal cord is exposed. Infection can lead to serious complications. Administering broad-spectrum antibiotics helps to reduce the risk of infection. Cleansing the site with Povidone iodine (choice B) is important, but antibiotics are necessary for prophylaxis. Monitoring rectal temperature (choice C) is not directly related to preventing infection. Surgical closure (choice D) after 72 hours is important, but antibiotics are essential immediately post-birth to prevent infection.
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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 caring for a client who is 36 weeks gestation and has MRSA. Which of the following isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective environment
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. MRSA is primarily spread through direct contact with an infected person or contaminated surfaces. By implementing contact precautions, the nurse can prevent the transmission of MRSA to other patients or healthcare workers. Droplet precautions (choice A) are used for diseases spread via respiratory droplets, such as influenza. Airborne precautions (choice C) are for diseases transmitted through small particles in the air, like tuberculosis. Protective environment (choice D) is used for immunocompromised patients to protect them from environmental pathogens. In this scenario, contact precautions are the most appropriate choice to prevent the spread of MRSA.
A nurse is assessing a client during her first prenatal visit the client reports March 20th us her last menstrual.. Use Niagele9s rule to calculate the estimated date of delivery. Use the mmdd format with four numerals and no spaces or punctuation.
- A. 05/11
- B. 5/4
- C. 5/12
- D. 04/27
Correct Answer: A
Rationale: The correct answer is A: 05/11. Using Naegele's rule, add 7 days to the first day of the last menstrual period (March 20), subtract 3 months, and add 1 year. March 20 + 7 days = March 27. Subtracting 3 months gives us December 27. Adding 1 year brings us to December 27 of the following year. However, since we are looking for the estimated date of delivery, we add 7 days to adjust for the 7 days we added at the beginning, which gives us May 4. Therefore, the estimated date of delivery would be May 11. Choice B (5/4) is incorrect because it does not account for the 7-day adjustment. Choice C (5/12) is incorrect as it adds 7 days twice. Choice D (04/27) is incorrect as it doesn't correctly follow Naegele's rule.
A nurse is caring for a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Firm rigid abdomen
- B. Painless, vaginal bleeding
- C. Uterine hypertonicity
- D. Persistent headache
Correct Answer: B
Rationale: The correct answer is B: Painless, vaginal bleeding. Placenta previa is a condition where the placenta partially or completely covers the cervix, leading to painless, bright red bleeding in the third trimester. This occurs because the placenta is located close to or over the cervical opening, causing it to bleed with minimal trauma. It is important for the nurse to recognize this sign as it can lead to maternal and fetal complications if not managed promptly. Choices A, C, and D are incorrect because they do not align with the typical presentation of placenta previa. A firm rigid abdomen is more indicative of a condition like placental abruption. Uterine hypertonicity is not a common finding in placenta previa. Persistent headache is not a characteristic symptom of placenta previa and may be indicative of other conditions like preeclampsia.
A nurse is providing discharge teaching to a postpartum client about caring for her five-year 5day old male newborn at home. Which of the following statements should the nurse make to the client?
- 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 as decreased urine output can indicate dehydration in a newborn, which is a serious concern. It is crucial to monitor the baby's hydration status closely in the early days of life.
A: Retracting the foreskin to clean the baby's penis is not recommended as it can cause harm and is not necessary at this age.
B: Using triple antibiotic ointment on the umbilical cord is not recommended as it can delay the natural healing process.
C: Swaddling the baby tightly with legs extended is not recommended as it can increase the risk of hip dysplasia.
In summary, the other choices are incorrect because they may cause harm or are not recommended practices for caring for a newborn.