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After the delivery of a neonate, a quick assessment is completed. The neonate is found to be apneic. After quickly drying the neonate, what should the nurse do next?
- A. Assign the first Apgar score.
- B. Place the head in a 'sniff' position.
- C. Administer oxygen.
- D. Start cardiac compressions.
Correct Answer: B
Rationale: Placing the head in a 'sniff' position opens the airway, which is critical for an apneic neonate before further interventions.
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Which of the following would the nurse expect to assess in a neonate delivered at 28 weeks' gestation who is diagnosed with intraventricular hemorrhage (IVH)?
- A. Increased muscle tone.
- B. Hyperbilirubinemia.
- C. Bulging fontanels.
- D. Hyperactivity.
Correct Answer: C
Rationale: Bulging fontanels are a sign of increased intracranial pressure from IVH in preterm neonates.
A nurse is counseling a client about the use of a diaphragm for contraception. Which of the following instructions should the nurse include?
- A. Insert the diaphragm up to 6 hours before intercourse.
- B. Remove the diaphragm immediately after intercourse.
- C. Use a spermicide with the diaphragm for each act of intercourse.
- D. Store the diaphragm in a dry, airtight container.
Correct Answer: C
Rationale: Using spermicide with the diaphragm for each act of intercourse is essential for effectiveness. The diaphragm can be inserted up to 6 hours before and left in place for at least 6 hours after intercourse but not more than 24 hours. It should be stored in a clean, dry container, not necessarily airtight.
After explaining to a primiparous client about the causes of her neonate's cranial molding, which of the following statements by the mother indicates the need for further instruction?
- A. The molding was caused by an overlapping of the baby's cranial bones during my labor.'
- B. The amount of molding is related to the amount and length of pressure on the head.'
- C. The molding will usually disappear in a couple of days.'
- D. Brain damage may occur if the molding doesn't resolve quickly.'
Correct Answer: D
Rationale: Cranial molding is a normal process that resolves within days and does not cause brain damage, indicating the mother needs further instruction.
A primigravid client at 37 weeks' gestation has been hospitalized for several days with severe pregnancy-induced hypertension. While caring for the client, the nurse observes that the client is beginning to have a seizure. Which of the following actions should the nurse do first?
- A. Pad the side rails of the client's bed.
- B. Turn the client to the right side.
- C. Insert a padded tongue blade into the client's mouth.
- D. Call for immediate assistance in the client's room.
Correct Answer: D
Rationale: A seizure in pregnancy-induced hypertension (eclampsia) is a medical emergency. Calling for immediate assistance ensures rapid intervention (e.g., magnesium sulfate). Padding rails, repositioning, or inserting a tongue blade (which is outdated) are secondary.
A nurse is teaching a client about the fertility awareness method. Which of the following instructions should the nurse include?
- A. Track basal body temperature and cervical mucus daily.
- B. Avoid intercourse throughout the entire menstrual cycle.
- C. Use this method if you have irregular periods.
- D. Monitor ovulation with a home pregnancy test.
Correct Answer: A
Rationale: Tracking basal body temperature and cervical mucus daily is essential for the fertility awareness method to identify fertile days. Intercourse is avoided only during fertile periods, the method is less reliable with irregular periods, and pregnancy tests do not monitor ovulation.