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Client being admitted for induction of labor.
A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby in any public birth announcements to social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct Answer: A
Rationale: Checking the identification badge ensures the individual removing the baby is authorized, reducing the risk of abduction. This is a recommended safety practice in hospital settings to protect newborns.
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Client at 35 weeks of gestation experiencing mild vaginal bleeding due to placenta previa.
A nurse is admitting a client who is at 35 weeks of gestation and is experiencing mild vaginal bleeding due to placenta previa. Which of the following actions should the nurse plan to take?
- A. Initiate continuous monitoring of the FHR.
- B. Administer a dose of betamethasone.
- C. Check the cervix for dilation every 8 hr.
- D. Request that the provider prescribe misoprostol PRN.
Correct Answer: A,B
Rationale: Continuous monitoring of fetal heart rate (A) provides early detection of distress in placenta previa cases. Betamethasone (B) accelerates fetal lung maturity, reducing the risk of respiratory distress syndrome if preterm delivery occurs.
Newborn with a suspected condition.
Which of the following findings should the nurse identify as manifestations of the newborn's suspected condition?
- A. Mother's report of feedings.
- B. Oral mucosa findings.
- C. Respiratory findings.
- D. Temperature change.
Correct Answer: B,C
Rationale: Oral mucosa changes (B), such as pallor or cyanosis, may occur due to hypoxia or circulatory compromise. Respiratory changes (C), including tachypnea or retractions, are significant manifestations of stress or pulmonary involvement in neonatal conditions like asphyxia.
Newborn born two hours ago at 36 weeks gestation, findings: Bruising noted over occiput, yellowish hue on sclera and skin blanching, transcutaneous bilirubin level 12.5 mg/dL, phototherapy initiated.
A newborn born two hours ago at 36 weeks gestation has noted findings. Which findings are consistent with neonatal jaundice?
- A. Bruising noted over occiput.
- B. Yellowish hue on sclera and skin blanching.
- C. Transcutaneous bilirubin level 12.5 mg/dL (less than 12 mg/dL).
- D. Phototherapy initiated at 08:45.
Correct Answer: B,C,D
Rationale: Yellowish sclera and blanching skin (B), transcutaneous bilirubin level of 12.5 mg/dL (C), and phototherapy initiation (D) indicate neonatal jaundice from elevated bilirubin levels due to immature hepatic conjugation, requiring monitoring and treatment to prevent kernicterus.
Following this type of birth, the nurse should monitor the client for hemorrhage and monitor the newborn for facial nerve palsy. What additional care should the nurse consider?
- A. Administering prophylactic antibiotics to prevent infection.
- B. Assessing for signs of jaundice in the newborn.
- C. Monitoring the client's vital signs for stability.
- D. Educating the client on breastfeeding techniques.
Correct Answer: B
Rationale: Jaundice assessment is critical for newborns with facial bruising or cephalohematoma, as bilirubin levels may rise due to blood breakdown in the localized hematoma.
Parents of a newborn with an uncircumcised penis.
A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?
- A. Retract the foreskin until you feel resistance.
- B. Use a cotton swab to clean under the foreskin.
- C. Apply petroleum jelly to the foreskin.
- D. Wash the penis once per day with soap and water.
Correct Answer: D
Rationale: Daily washing with mild soap and water ensures proper hygiene and prevents infection. This method maintains cleanliness without causing harm to sensitive tissues.