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Postpartum woman, 4-day-old infant, breastfeeding
A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who:
- A. has at least six to eight wet diapers per day.
- B. has at least one breast milk stool every 24 hours.
- C. sleeps for 6 hours at a time between feedings.
- D. gains 1 to 2 ounces per week.
Correct Answer: A
Rationale: Six to eight wet diapers per day indicate adequate hydration and milk intake, a reliable sign of effective breastfeeding.
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Client in labor, external fetal monitor, late decelerations
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
- A. Uteroplacental insufficiency.
- B. Umbilical cord compression.
- C. Maternal bradycardia.
- D. Fetal head compression.
Correct Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency, where reduced placental blood flow during contractions causes fetal hypoxia.
Woman received 50 mcg fentanyl intravenously 1 hour before delivery
A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?
- A. Nalbuphine (Nubain).
- B. Naloxone (Narcan).
- C. Butorphanol (Stadol).
- D. Promethazine (Phenergan).
Correct Answer: B
Rationale: Naloxone (Narcan) reverses opioid effects like fentanyl, critical for addressing potential respiratory depression in the newborn.
2-day-old newborn
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
- A. Hyperbilirubinemia.
- B. Respiratory distress syndrome.
- C. Polycythemia.
- D. Transient tachypnea.
Correct Answer: A
Rationale: The increased breakdown of neonatal red blood cells, which have a shorter lifespan, produces bilirubin, leading to hyperbilirubinemia and potential jaundice.
Infant being weighed
The correct answer is choice A, which is to ensure that conductive heat loss from the infant is minimal
- A. ensure that conductive heat loss from the infant is minimal
- B. compensate for the negative weight balance to ensure the correct weight
- C. avoid causing multiple startle (Moro) reflexes when weighing
- D. avoid contaminating the nurse's hands with blood or other body substances
Correct Answer: A
Rationale: A covering on the scale tray minimizes conductive heat loss by preventing direct contact with the cold scale surface, critical for maintaining the infant's temperature.
Client at 40 weeks gestation, in labor, electronic fetal heart rate monitor tracing
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
- A. Accelerations.
- B. Late decelerations.
- C. Variable decelerations.
- D. Early decelerations.
Correct Answer: C
Rationale: Variable decelerations indicate fetal hypoxia due to umbilical cord compression, requiring urgent intervention as they suggest the cord is trapped or twisted, impairing fetal oxygen supply.