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After assisting with a vaginal delivery, what would the nurse do to prevent heat loss via conduction in the newborn?
- A. Dry the newborn with a warm blanket.
- B. Close the doors to the delivery room.
- C. Wrap the newborn in a blanket.
- D. Place the newborn on a warm crib pad.
Correct Answer: D
Rationale: The correct answer is D: Place the newborn on a warm crib pad. This helps prevent heat loss via conduction by providing a warm surface for the newborn to rest on, minimizing direct contact with a colder surface. Drying the newborn with a warm blanket (choice A) can help prevent heat loss via evaporation, not conduction. Closing the doors to the delivery room (choice B) may help maintain room temperature but does not directly prevent heat loss via conduction. Wrapping the newborn in a blanket (choice C) helps prevent heat loss via radiation, not conduction.
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A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse perform first?
- A. Cover the cord with a sterile, moist saline dressing.
- B. Place the client in knee-chest position.
- C. Prepare the client for an immediate birth.
- D. Insert a gloved hand into the vagina to relieve pressure on the cord.
Correct Answer: D
Rationale: The correct answer is D: Insert a gloved hand into the vagina to relieve pressure on the cord. This is the priority action in this situation to prevent cord compression, which can compromise fetal blood flow. By gently elevating the presenting part off the cord, the nurse can help restore blood flow to the baby. Covering the cord (A) or placing the client in the knee-chest position (B) are not as effective in relieving pressure on the cord. Preparing for an immediate birth (C) may be necessary but addressing the cord issue is the priority.
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, “How will I know if my baby gets enough breast milk?” Which of the following responses should the nurse make?
- A. Your baby should wet 6 to 8 diapers per day.
- B. Your baby should have a wake cycle of 30 to 60 minutes after each feeding.
- C. Your baby should burp after each feeding.
- D. Your baby should sleep at least 6 hours between feedings.
Correct Answer: A
Rationale: The correct answer is A: Your baby should wet 6 to 8 diapers per day. This is because the frequency of wet diapers indicates that the newborn is getting enough breast milk. An adequate amount of wet diapers signifies that the baby is adequately hydrated and receiving sufficient nourishment. It is a concrete and measurable way to monitor the baby's intake.
Choice B is incorrect because the wake cycle after feeding varies among newborns and is not a reliable indicator of milk intake. Choice C is incorrect as burping after feeding is a normal process but not necessarily an indicator of sufficient milk intake. Choice D is incorrect because newborns typically need to feed more frequently than every 6 hours.
A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia?
- A. 3+ protein in the urine.
- B. Deep tendon reflexes of 1+.
- C. Blood pressure 148/98 mm Hg.
- D. 1+ pitting sacral edema.
Correct Answer: B
Rationale: The correct answer is B. Deep tendon reflexes of 1+ are inconsistent with preeclampsia. In preeclampsia, deep tendon reflexes are typically hyperactive (3+ or 4+). This is due to the central nervous system irritability caused by hypertension. Therefore, a reflex of 1+ suggests normal reflexes, which is not expected in preeclampsia. Other choices A, C, and D are consistent with preeclampsia. Proteinuria (choice A) is a hallmark sign of preeclampsia. Elevated blood pressure (choice C) is a common finding in preeclampsia. Pitting edema (choice D) is also commonly observed in preeclampsia due to fluid retention.
A nurse is assessing a newborn who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Absent plantar reflexes
- C. Lengthened thigh on the affected side
- D. Asymmetric thigh folds
Correct Answer: D
Rationale: The correct answer is D: Asymmetric thigh folds. In DDH, there is an abnormal formation of the hip joint which can lead to dislocation. Asymmetric thigh folds result from the shortened thigh muscles on the affected side due to the dislocation. This finding is indicative of DDH as it reflects the displacement of the femoral head. The other choices are incorrect because an inwardly turned foot (A) is associated with clubfoot, absent plantar reflexes (B) may indicate neurological issues, and a lengthened thigh (C) is not a typical finding in DDH.
A nurse is caring for a newborn delivered by vaginal birth with a vacuum assist. The newborn’s mother asks about the swollen area on her son’s head. After palpation to identify that the swelling crosses the suture line, which of the following is an appropriate response by the nurse?
- A. This is a cephalohematoma which can occur spontaneously.
- B. A caput succedaneum will subside in a few days.
- C. Mongolian spots can be found on the skin of many newborns.
- D. This is a telangiectatic nevus and no treatment is needed.
Correct Answer: B
Rationale: The correct answer is B: A caput succedaneum will subside in a few days. A caput succedaneum is a diffuse swelling of the scalp that occurs due to pressure on the baby's head during labor. It typically resolves on its own within a few days. In this scenario, since the swelling crosses the suture line, it is likely a caput succedaneum. Palpation of the swelling helps to differentiate it from cephalohematoma, which is confined by suture lines. Choice A is incorrect because a cephalohematoma is a collection of blood between the periosteum and skull bone, not the same as caput succedaneum. Choices C and D are incorrect as they refer to different conditions unrelated to the swelling on the newborn's head.