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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 in a clinic a caring for a 16-year-old adolescent
Exhibit1:
Provider Prescriptions: Standing prescriptions for clients who present with abdominal. Obtain laboratory
tests, Urinalysis, Cervical culture C-reactive protein Beta Hcg
Which of the following findings should the nurse report to the provider? Select all that apply
- A. Abdominal assessment.
- B. Vaginal Discharge.
- C. Heart rate.
- D. Temperature.
- E. Dyspareunia.
- F. Condom usage.
Correct Answer: B, E
Rationale:
The nurse should report vaginal discharge (B) as it could indicate infection or other issues. Dyspareunia (E) should also be reported as it can indicate underlying problems. Abdominal assessment (A) may be part of routine care but doesn't necessarily require immediate reporting. Heart rate (C) and temperature (D) are vital signs that should be monitored but don't specifically indicate a need for immediate reporting. Condom usage (F) is important for sexual health discussions but does not require reporting to the provider.
“A nurse is caring tor a newborn.
Exhibit1:
Medical History. Apgar score 9 at 1 min and 9 at 5 min Birth weight 4,706 g (10 lb 6 oz)| Gestational age
40 weeks Difficult vaginal birth with shoulder dystocia.
EXHIBIT2:
Nurses: Notes 1700: Newborn is active and moves all extremities except for right arm. No spontaneous
movement of the right arm noted, Right arm remains at side during Moro reflex.
Exhibit3:
Physical examination 1830: Absent Moro reflex noted in right arm. Right shoulder and arm are internally
rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed. Diagnosis.
brachial prexus injury resulting in trot Duchenne (Erb's palsy) paralysis
Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is Indicated or contraindicated for the newborn
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer: B
Rationale: [0, 1, 0, 0]
Assess for grasp reflex in the affected extremity is the correct answer. This action is indicated as it allows the nurse to evaluate neurological function and muscle strength in the affected arm without causing harm. Educating parents to begin range of motion exercises after 1 week (A) is contraindicated as it may exacerbate injury or delay healing. Immobilizing the arm across the abdomen (C) is also contraindicated as it can restrict movement and hinder recovery. Instructing parents to limit physical handling for 2 weeks (D) is not the best option as it may not provide the necessary assessment and treatment for the newborn's condition.
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?
- A. Blood pressure 105/64 mm Hg.
- B. Heart rate 98/min.
- C. Urine output of 280 mL within 8 hr.
- D. Urine negative for ketones.
Correct Answer: C
Rationale: The correct answer is C: Urine output of 280 mL within 8 hr. In hyperemesis gravidarum, excessive vomiting leads to dehydration and electrolyte imbalance. Monitoring urine output is crucial for assessing renal perfusion. A urine output of 280 mL in 8 hours is low, indicating possible renal impairment. This finding should be reported to the provider for further evaluation and intervention. Choices A, B, and D are within normal limits for a client with hyperemesis gravidarum and receiving IV fluids. Blood pressure of 105/64 mm Hg is acceptable, heart rate of 98/min is slightly elevated but not alarming, and urine negative for ketones indicates adequate fluid replacement.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan?
- A. Feed the newborn 1 oz of water every 4 hr.
- B. Apply lotion to the newborn's skin three times per day.
- C. Remove all clothing from the newborn except the diaper.
- D. Discontinue therapy if the newborn develops a rash.
Correct Answer: C
Rationale: The correct answer is C. Removing all clothing from the newborn except the diaper during phototherapy is essential as it helps maximize the skin surface area exposed to the light, thus enhancing the effectiveness of the treatment. This allows for better absorption of the light by the skin, aiding in the breakdown of bilirubin.
A: Feeding the newborn water every 4 hours is not directly related to phototherapy for hyperbilirubinemia.
B: Applying lotion to the newborn's skin may interfere with the effectiveness of phototherapy and should be avoided.
D: Discontinuing therapy if a rash develops is not advisable, as a rash is a common side effect of phototherapy and does not necessarily require therapy cessation.
A nurse is admitting a client to the labor and delivery unit when the client states, 'My water just broke.' Which of the following interventions is the nurse's priority?
- A. Perform Nitrazine testing.
- B. Assess the fluid.
- C. Check cervical dilation.
- D. Begin FHR monitoring.
Correct Answer: D
Rationale: The correct answer is D: Begin FHR monitoring. This is the priority intervention because it assesses the well-being of the fetus immediately after the client's water breaking. Monitoring the fetal heart rate can provide crucial information on the baby's status and help identify any signs of distress. Performing Nitrazine testing (A) or checking cervical dilation (C) can be done after ensuring fetal well-being. Assessing the fluid (B) can confirm if the amniotic sac has indeed ruptured but does not provide immediate information on fetal status.