Nokea
A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse's most appropriate action?
- A. Contact the hospital chaplain.
- B. Request the couple's clergy.
- C. Baptize the newborn.
- D. Ask the physician to baptize the newborn.
Correct Answer: C
Rationale: If the condition of a newborn is poor, the parents may wish to have a baptism performed. In an emergency, the nurse may perform the baptism by pouring water on the infant's forehead while saying, 'I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.'
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What instruction should the nurse teach the postpartum woman about perineal self-care?
- A. Perform perineal self-care at least twice a day.
- B. Cleanse with warm water in a squeeze bottle from front to back.
- C. Remove perineal pads from the rectal area toward the vagina.
- D. Use cool water to decrease edema of the perineum.
Correct Answer: B
Rationale: Cleansing from front to back prevents contamination from the rectal area.
What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
- A. Well-contracted with its upper border at or just below the umbilicus
- B. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
- C. Relaxed with its upper border level with the umbilicus
- D. Relaxed with its upper border two or three fingerbreadths below the umbilicus
Correct Answer: A
Rationale: Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.
While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.)
- A. Ready-to-feed formula
- B. Concentrated liquid formula
- C. Powdered formula
- D. Cow's milk
- E. Canned evaporated milk
Correct Answer: A,B,C
Rationale: Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infant's needs, and powdered formula that is mixed as needed. Cow's milk and canned evaporated milk are unsuitable, because they are nutritionally inadequate and stress the kidneys.
Below what blood glucose level is the newborn considered hypoglycemic?
- A. Below 70 mg/dL
- B. Below 60 mg/dL
- C. Below 50 mg/dL
- D. Below 40 mg/dL
Correct Answer: D
Rationale: A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.
In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment?
- A. Palpate from the midline to the side of the body.
- B. Palpate from the symphysis to the umbilicus.
- C. Palpate from the side of the uterus to the midline.
- D. Massage the abdomen in a circular motion.
Correct Answer: C
Rationale: The fundus is checked gently by walking the fingers from the side of the uterus to the midline.