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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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A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?
- A. Check the newborn's temperature every 8 hours.
- B. Apply moisturizing lotion to the newborn's skin every 4 hours.
- C. Reposition the newborn every 2 to 3 hours.
- D. Give the newborn 1 oz of glucose water every 4 hours.
Correct Answer: C
Rationale: Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.
A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day.
- B. Initiate seizure precautions for the client.
- C. Encourage the client to ambulate twice per day.
- D. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr.
Correct Answer: B
Rationale: Seizure precautions are necessary in preeclampsia due to the risk of eclampsia from uncontrolled blood pressure. Measures include bedrails padding and medication administration to reduce seizure occurrences.
For each body system below, specify the potential complications that can occur. Match the body system with the potential complications.
- A. Hypotonia
- B. Seizures
- C. Hearing loss
Correct Answer: B
Rationale: Neurologic: Seizures (B) - due to potential neurological dysfunction. Musculoskeletal: Hypotonia (A) - indicating muscle weakness. Head, ears, eyes, nose, and throat: Hearing loss (C) - from auditory nerve or structural damage.
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.