Nokea
A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. The nurse will carry your baby in their arms to the nursery for scheduled procedures.
- B. We will document the relationship of visitors in your medical record.
- C. It is okay for your baby to sleep in the bed with you while in the hospital.
- D. Staff members who take care of your baby will be wearing a photo identification badge.
Correct Answer: D
Rationale: The correct answer is D: Staff members who take care of your baby will be wearing a photo identification badge. This statement promotes the security and safety of the newborn by ensuring that only authorized personnel are handling the baby. It helps prevent unauthorized individuals from gaining access to the newborn. This practice aligns with hospital security protocols and minimizes the risk of infant abduction or mix-ups.
Choice A is incorrect as it goes against current safety practices of not carrying newborns to the nursery by non-parents for security reasons. Choice B is unrelated to the security and safety of the newborn. Choice C is incorrect as it goes against safe sleep guidelines which recommend placing the baby in a separate sleep area to reduce the risk of Sudden Infant Death Syndrome (SIDS).
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A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?
- A. Hypertonia.
- B. Increased feeding.
- C. Hyperthermia.
- D. Respiratory distress.
Correct Answer: D
Rationale: The correct answer is D: Respiratory distress. Hypoglycemia in a late preterm newborn can lead to respiratory distress due to decreased glucose levels affecting cellular function and energy production. Hypertonia (choice A) is not typically associated with hypoglycemia in newborns. Increased feeding (choice B) may be a response to hypoglycemia but is not a direct manifestation. Hyperthermia (choice C) is not a common sign of hypoglycemia. Therefore, the correct choice is D as it directly reflects the impact of low glucose levels on respiratory function.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?
- A. The test should take 10 to 15 minutes to complete.
- B. You will lie in a supine position throughout the test.
- C. You should not eat or drink for hours before the test.
- D. You should press the handheld button when you feel your baby move.
Correct Answer: D
Rationale: Rationale: Option D is the correct answer because in a nonstress test, the client is required to press a handheld button every time they feel their baby move. This action helps to monitor the baby's heart rate in response to its movements, providing valuable information about the baby's well-being. This is essential at 37 weeks of gestation to ensure the baby is healthy and responding appropriately.
Summary of other choices:
A: Incorrect - The test duration can vary, but it typically takes longer than 10 to 15 minutes.
B: Incorrect - The client may need to change positions during the test to optimize fetal monitoring.
C: Incorrect - It is important for the client to eat and stay hydrated before the test to encourage fetal movement.
E, F, G: Choices not provided, thus irrelevant.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?
- A. Acrocyanosis.
- B. Transient strabismus.
- C. Jaundice.
- D. Caput succedaneum.
Correct Answer: C
Rationale: The correct answer is C: Jaundice. Jaundice in a newborn within the first 24 hours can indicate pathological conditions like hemolytic disease or liver dysfunction, requiring immediate attention. Acrocyanosis (A) and caput succedaneum (D) are common benign conditions in newborns. Transient strabismus (B) is a temporary eye misalignment that often resolves on its own. Other choices are not provided.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation.
- B. Temperature.
- C. Blood pressure.
- D. Urinary output.
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is a risk of infection due to the introduction of bacteria into the amniotic fluid. Monitoring the client's temperature is crucial as an elevated temperature could indicate infection, which can be life-threatening for both the mother and the fetus. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but not the priority in this situation. O2 saturation is typically monitored continuously during labor, blood pressure can fluctuate during labor but is not directly impacted by amniotomy, and urinary output is important for assessing hydration status but does not take precedence over monitoring for infection.
A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?
- A. Percutaneous umbilical blood sampling.
- B. Amnioinfusion.
- C. Biophysical profile (BPP).
- D. Chorionic villus sampling (CVS).
Correct Answer: C
Rationale: The correct answer is C: Biophysical profile (BPP). At 41 weeks of gestation, a positive contraction stress test indicates potential placental insufficiency. A BPP assesses fetal well-being by evaluating fetal movement, muscle tone, breathing, amniotic fluid volume, and heart rate reactivity. This test helps determine the need for immediate delivery.
Percutaneous umbilical blood sampling (A) is used to directly sample fetal blood for genetic testing and not for assessing fetal well-being. Amnioinfusion (B) is used to increase amniotic fluid volume during labor and not for evaluating fetal well-being. Chorionic villus sampling (D) is an invasive prenatal diagnostic test for genetic abnormalities and not for assessing fetal well-being.