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A nurse on a labor and delivery unit is receiving infection control standards with a newly licensed nurse. The nurse should instruct the newly licensed nurse to don gloves for which of the following procedures?
- A. Assisting a mother with breastfeeding
- B. Performing a newborn’s initial bath
- C. Administering the measles, mumps, rubella vaccine
- D. Performing umbilical cord care
Correct Answer: D
Rationale: The correct answer is D: Performing umbilical cord care. Gloves should be worn when performing this procedure to prevent potential infection transmission. The umbilical cord stump is a point of entry for pathogens, making it important to maintain strict infection control. Assisting a mother with breastfeeding (A) does not require gloves unless there are open wounds or sores on the mother's breast. Performing a newborn’s initial bath (B) does not necessitate gloves unless there are specific concerns like skin conditions. Administering the measles, mumps, rubella vaccine (C) typically requires clean, not sterile, technique. In summary, wearing gloves during umbilical cord care is essential to prevent infection transmission, making it the correct choice in this scenario.
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A nurse is caring for a client who is receiving prenatal care and is at her 24-week appointment. Which of the following laboratory tests should the nurse plan to conduct?
- A. 1-hour glucose tolerance test
- B. Rubella titer
- C. Group B strep culture
- D. Blood type and Rh
Correct Answer: A
Rationale: The correct answer is A: 1-hour glucose tolerance test. At 24 weeks, it is important to screen for gestational diabetes. This test helps assess the body's ability to metabolize glucose. The other choices are not typically done at the 24-week appointment. B: Rubella titer is usually done earlier in pregnancy to check immunity. C: Group B strep culture is usually done around 35-37 weeks. D: Blood type and Rh are usually checked at the first prenatal visit.
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.
A nurse is planning care for a newborn who is scheduled to start phototherapy using a lap.
- A. Apply a thin layer lotion to the newborn's skin every 8 hours
- B. Dress the newborn in a thin layer of clothing during the therapy
- C. Ensure the newborn's eyes are closed beneath the shield
- D. Give the newborn 1 oz of glucose water every 4 hours
Correct Answer: C
Rationale: The correct answer is C: Ensure the newborn's eyes are closed beneath the shield. During phototherapy, the newborn's eyes need to be protected from the bright lights to prevent potential eye damage. Closing the eyes beneath the shield helps to shield them from the light exposure. This step is crucial in preventing complications and ensuring the safety and well-being of the newborn.
Other choices are incorrect because:
A: Applying lotion to the newborn's skin may interfere with the effectiveness of the phototherapy and is not necessary for the treatment.
B: Dressing the newborn in clothing may also interfere with the effectiveness of the phototherapy as the light needs direct contact with the skin.
D: Giving glucose water every 4 hours is not indicated for phototherapy and may not be appropriate for the newborn's condition.
In summary, ensuring the newborn's eyes are closed beneath the shield is the correct choice as it is essential for the safety and effectiveness of the phototherapy treatment.
A nurse is assessing a newborn whose mother had a primary cytomegalovirus (CMV) infection during pregnancy. The newborn acquired CMV transplacentally. Which of the following findings should the nurse expect the newborn to exhibit?
- A. Urinary tract infection
- B. Hearing loss
- C. Macrosomia
- D. Cataracts
Correct Answer: B
Rationale: The correct answer is B: Hearing loss. CMV infection during pregnancy can lead to congenital CMV in newborns, resulting in various complications. Hearing loss is a common manifestation of congenital CMV infection. The virus can damage the inner ear structures, leading to sensorineural hearing loss. This complication is crucial to monitor and address early to prevent long-term consequences.
Incorrect choices:
A: Urinary tract infection - Not typically associated with congenital CMV infection.
C: Macrosomia - Excessive birth weight, not a common manifestation of congenital CMV infection.
D: Cataracts - Uncommon in congenital CMV infection; typically associated with other congenital infections like rubella.
A nurse is caring for four antepartum clients. Which of the following clients should the nurse assess first?
- A. A client who is at 7 weeks of gestation and reports urinary frequency
- B. A client who is at 32 weeks of gestation and reports seeing floating spots
- C. A client who is 38 weeks of gestation and reports leg cramps
- D. A client who is at 20 weeks of gestation and reports periodic numbness in her fingers
Correct Answer: B
Rationale: The correct answer is B. The nurse should assess the client who is at 32 weeks of gestation and reports seeing floating spots first. Seeing floating spots could be a sign of preeclampsia, a serious pregnancy complication characterized by high blood pressure and organ damage. Preeclampsia can lead to severe complications for both the mother and the baby if not managed promptly. Therefore, this client needs immediate assessment to rule out preeclampsia and ensure appropriate interventions are initiated. Choices A, C, and D do not present with urgent signs or symptoms that require immediate attention compared to the potential severity of preeclampsia in choice B.