Nokea
Newborns in nursery
A nurse receives handoff report. Which newborn should the nurse assess first?
- A. Glucose reading 58 mg/dL.
- B. Pulse 144 beats/minute.
- C. Respiratory rate 78 breaths/minute.
- D. Temperature 97.7° F (36.5° C).
Correct Answer: C
Rationale: A respiratory rate of 78 breaths/minute indicates tachypnea, suggesting potential respiratory distress, which requires immediate assessment.
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Newborn immediately after birth
The priority nursing care of the newborn immediately after birth includes all except:
- A. Support thermoregulation.
- B. Identify the infant.
- C. Promote normal respirations.
- D. Announcement of the delivery.
Correct Answer: D
Rationale: Announcement of the delivery is not a priority in nursing care of the newborn immediately after birth. While it may be a joyful moment for the parents and family, it does not affect the health and well-being of the newborn. Therefore, it can be done later after the essential newborn care has been completed.
Client 2 hours postpartum, vaginal birth, saturated two perineal pads in 30 minutes
A nurse is caring for a client 2 hours after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?
- A. Assist the client on a bedpan to urinate.
- B. Increase the client's fluid intake.
- C. Palpate the client's uterine fundus.
- D. Prepare to administer oxytocic medication.
Correct Answer: C
Rationale: Palpating the uterine fundus assesses for uterine atony, a common cause of postpartum hemorrhage indicated by excessive bleeding.
Client receiving opioid epidural analgesia during labor
A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?
- A. Blood pressure 80/56 mm Hg.
- B. The client reports profuse itching.
- C. The client reports weakness of the lower extremities.
- D. Temperature 38.2°C (100.8 F).
Correct Answer: A
Rationale: Hypotension (80/56 mm Hg) is the priority as it can reduce placental blood flow, risking fetal distress, and requires immediate intervention.
Client after amniotomy
After an amniotomy, which action by the nurse takes priority?
- A. Change the patient's gown.
- B. Assess the fetal heart rate.
- C. Estimate the amount of amniotic fluid.
- D. Assess the color of the amniotic fluid.
Correct Answer: B
Rationale: Assessing the fetal heart rate is the priority after an amniotomy to ensure the fetus tolerates the procedure and detect any distress.
Newborn placed under radiant heat warmer after birth
A nurse places a newborn under a radiant heat warmer after birth. The purpose of this action is to prevent which of the following in the newborn?
- A. Basal metabolic rate reduction.
- B. Brown fat production.
- C. Shivering.
- D. Cold stress.
Correct Answer: D
Rationale: A radiant heat warmer prevents cold stress by maintaining the newborn's body temperature, avoiding complications like hypoxia and hypoglycemia.