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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.
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Woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday, orders for perineal ice packs, sitz bath, stool softener
A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?
- A. The woman had a vacuum-assisted birth.
- B. The woman is a gravida 2, para 2.
- C. The woman has an episiotomy.
- D. The woman received epidural anesthesia.
Correct Answer: C
Rationale: An episiotomy correlates with orders for ice packs, sitz baths, and stool softeners, as these address pain and healing of the perineal incision.
Student nurse learning about milk production
The student nurse learns that the hormone necessary for milk production is
- A. Estrogen.
- B. Prolactin.
- C. Progesterone.
- D. Lactogen.
Correct Answer: B
Rationale: Prolactin, secreted by the pituitary gland, is responsible for milk production, especially after delivery when estrogen and progesterone levels drop.
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.
Newborn born 10 hours ago via cesarean section, moist lung sounds
A nursing student is helping the nursery nurses with morning vital signs. A baby born 10 hours ago via cesarean section is found to have moist lung sounds. What is the best interpretation of these data?
- A. If this baby was born vaginally, it could indicate a pneumothorax.
- B. The neonate must have aspirated surfactant.
- C. The lungs of a baby delivered by cesarean section may sound moist for 24 hours after birth.
- D. The nurse should notify the pediatrician stat for this emergency situation.
Correct Answer: C
Rationale: Babies born via cesarean section often have moist lung sounds due to retained fluid, as they miss the chest compression of vaginal delivery, and this typically resolves within 24 hours.
Male newborn, genitalia assessment
The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment?
- A. Inspecting if the urethral opening appears circular.
- B. Retracting the foreskin over the glans to assess for secretions.
- C. Palpating if testes are descended into the scrotal sac.
- D. Inspecting the genital area for irritated skin.
Correct Answer: B
Rationale: Retracting the foreskin over the glans should be avoided as it can cause pain, bleeding, and infection in the newborn. The foreskin is usually adhered to the glans and should not be forcibly retracted.