Nokea
A nurse is preparing to assess a newborn who is post-term. Which of the following findings should the nurse expect? (Select all that apply)
- A. Vernix in the folds and creases
- B. Abundant lanugo
- C. Positive Moro reflex
- D. Cracked peeling skin
- E. Short soft fingernails
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A post-term newborn is born after 42 weeks of gestation, which can lead to certain physical characteristics.
A: Vernix in the folds and creases is expected in post-term newborns due to prolonged exposure to amniotic fluid.
C: Positive Moro reflex is expected as it indicates the baby's neurological maturity.
D: Cracked peeling skin is common in post-term newborns due to prolonged exposure to amniotic fluid, leading to dryness.
B: Abundant lanugo is typically seen in premature newborns rather than post-term.
E: Short soft fingernails are not specific to post-term newborns.
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A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn’s chest circumference?
- A. Intercostal space
- B. Xiphoid process
- C. Sternal notch
- D. Nipple line
Correct Answer: D
Rationale: The correct answer is D: Nipple line. When measuring a newborn's chest circumference, the nurse should use the nipple line as the anatomical landmark. This is because the nipple line is a consistent and reliable reference point for chest measurements in newborns. The other choices are not suitable landmarks for chest circumference measurement in newborns. A: Intercostal space is not a specific point for measurement. B: Xiphoid process is too low and not commonly used for chest measurements. C: Sternal notch is not a precise point for chest circumference measurement in newborns. Therefore, D: Nipple line is the most appropriate anatomical landmark for accurate chest circumference measurement in newborns.
A nurse is preparing to administer vitamin K by IM injection to a newborn. The nurse should administer the medication into which of the following muscles?
- A. Dorsogluteal
- B. Vastus lateralis
- C. Deltoid
- D. Ventrogluteal
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis. This muscle is the preferred site for IM injections in infants due to its large muscle mass and minimal risk of injury to nerves and blood vessels. The dorsogluteal site (choice A) is not recommended for neonates due to the risk of damaging the sciatic nerve. The deltoid muscle (choice C) is not suitable for newborns as it lacks adequate muscle mass and can lead to nerve injury. The ventrogluteal site (choice D) can be used in older infants but is not the preferred site for newborns.
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.
A nurse in the ambulatory surgery center is providing discharge teaching to a client who had a dilation and curettage (D&C) following a spontaneous miscarriage. Which of the following should be included in the teaching?
- A. Products of conception will be present in vaginal bleeding.
- B. Increased intake of zinc-rich foods is recommended.
- C. Vaginal intercourse can be resumed after 2 weeks.
- D. Aspirin may be taken for cramps.
Correct Answer: C
Rationale: The correct answer is C: Vaginal intercourse can be resumed after 2 weeks. This is important to prevent infection and allow the cervix to heal. Choice A is incorrect as products of conception are typically expelled during the D&C procedure. Choice B is irrelevant as zinc intake is not directly related to post-D&C care. Choice D is incorrect as aspirin can increase the risk of bleeding post-D&C.
A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 97.6°F. Which of the following is the priority nursing action?
- A. Witness the signature for informed consent for surgery.
- B. Initiate IV access.
- C. Insert an indwelling urinary catheter.
- D. Prepare the abdominal and perineal areas.
Correct Answer: B
Rationale: The correct answer is B: Initiate IV access. The priority nursing action in this scenario is to ensure IV access to administer necessary medications or fluids in case of an emergency. The client's vital signs indicate hypotension and tachycardia, which could be signs of hypovolemic shock due to significant bleeding. Initiating IV access promptly can help stabilize the client's condition and prevent further complications.
Choice A is incorrect because obtaining informed consent for surgery is not the immediate priority in this situation. Choice C is incorrect as inserting a urinary catheter is not urgent compared to addressing the potential hypovolemia. Choice D is incorrect as preparing the abdominal and perineal areas is not as urgent as addressing the client's hemodynamic instability.