Nokea
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?
- A. Ensure that the parent's identification band number matches the newborn's identification band number.
- B. Ask the parent to verify their name and date of birth.
- C. Check the newborn's security tag number to ensure it matches the newborn's medical record.
- D. Match the newborn's date and time of birth to the information in the parent's medical record.
Correct Answer: A
Rationale: The correct answer is A: Ensure that the parent's identification band number matches the newborn's identification band number. This is crucial for patient safety and identification to prevent mix-ups. Matching the identification band numbers ensures that the newborn is returned to the correct parent. Checking the parent's identification ensures that the parent is indeed the one authorized to receive the newborn. Choices B, C, and D do not directly address the vital step of verifying the parent-newborn match through identification band numbers, making them incorrect.
You may also like to solve these questions
A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?
- A. Increased fetal movement
- B. Leakage of fluid from the vagina
- C. Upper abdominal discomfort
- D. Urinary frequency
Correct Answer: B
Rationale: Correct Answer: B - Leakage of fluid from the vagina
Rationale: Following an amniocentesis at 18 weeks of gestation, leakage of fluid from the vagina could indicate a potential complication such as premature rupture of membranes. This complication could lead to preterm labor and pose a risk to both the mother and the fetus.
Summary of Other Choices:
A: Increased fetal movement - Normal fetal movement is expected following an amniocentesis and does not necessarily indicate a complication.
C: Upper abdominal discomfort - Common after an amniocentesis due to the needle insertion but usually resolves without major issues.
D: Urinary frequency - Not directly related to complications following an amniocentesis at 18 weeks gestation.
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 inadequate glucose supply to the brain, causing neurologic dysfunction. Hypertonia (choice A) is more indicative of hypocalcemia. Increased feeding (choice B) is not a typical manifestation of hypoglycemia. Hyperthermia (choice C) is not directly related to hypoglycemia. In summary, respiratory distress is a key sign of hypoglycemia in a late preterm newborn, while the other choices are not specific indicators.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The client being 80% effaced and 8 cm dilated indicates she is in active labor, not at risk for ectopic pregnancy (A). Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, unrelated to cervical dilation. Incompetent cervix (C) is characterized by painless cervical dilation in the second trimester. Postpartum hemorrhage (D) is a risk due to the advanced cervical dilation and effacement, making it more likely for excessive bleeding during and after delivery.
A nurse is caring for a client who is hypotensive following the administration of epidural anesthesia. Which of the following actions should the nurse take?
- A. Turn the client to a side-lying position.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Massage the client’s fundus.
- D. Assist the client to empty their bladder.
Correct Answer: A
Rationale: The correct answer is A: Turn the client to a side-lying position. This action helps prevent aortocaval compression, a potential cause of hypotension after epidural anesthesia. When the client is lying on their back, the weight of the uterus can compress the vena cava, reducing venous return and cardiac output, leading to hypotension. Turning the client to a side-lying position relieves this compression, improving blood flow and helping to stabilize blood pressure.
Summary:
B: Applying oxygen may be beneficial in some cases, but it does not directly address the underlying cause of hypotension in this scenario.
C: Massaging the fundus is not indicated for hypotension following epidural anesthesia.
D: Assisting the client to empty their bladder may be important for overall comfort and prevention of complications, but it does not address the hypotension directly.
A nurse is caring for a client who is 1 hr postpartum and has uterine atony. The client is exhibiting a large amount of vaginal bleeding. Which of the following actions should the nurse take?
- A. Administer betamethasone IM.
- B. Avoid performing sterile vaginal examinations.
- C. Anticipate a prescription for misoprostol.
- D. Obtain a specimen for a Kleihauer-Betke test.
Correct Answer: C
Rationale: Rationale: Choice C, anticipating a prescription for misoprostol, is correct. Misoprostol helps to contract the uterus and control bleeding in cases of uterine atony postpartum. Administering betamethasone (A) is used for fetal lung development, not for uterine atony. Avoiding sterile vaginal exams (B) is not helpful in managing uterine atony. Obtaining a specimen for a Kleihauer-Betke test (D) is used to detect fetal-maternal hemorrhage, not to manage uterine atony.