Nokea
Infant with axillary temperature of 35.9C (96.6F)
An infant's axillary temperature is 35.9C (96.6F). The priority nursing action is to:
- A. chart the normal axillary temperature.
- B. recheck the infant's temperature rectally.
- C. place the infant in a radiant warmer.
- D. have the mother breastfeed the infant.
Correct Answer: C
Rationale: The low temperature indicates hypothermia, and placing the infant in a radiant warmer is the priority to stabilize body temperature and prevent complications.
You may also like to solve these questions
Newborn born at 37 weeks, 12 hours old, tachypnea, grunting, nasal flaring, substernal retractions, acrocyanosis
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
- A. Initiate phototherapy as prescribed.
- B. Obtain a urine drug screen.
- C. Administer Surfactant as prescribed.
- D. Administer 30 mL of oral glucose water.
- E. Provide Oxygen Therapy as needed
- F. Hypoglycemia.
- G. Respiratory distress syndrome.
Correct Answer: B
Rationale: Respiratory distress syndrome is likely due to respiratory symptoms. Administer surfactant and provide oxygen therapy address lung immaturity and oxygenation. Monitor arterial blood gases and oxygen saturation to assess progress.
During vaginal delivery, newborn's head emerges
During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that
- A. The cord is still pulsating.
- B. The cord is intact.
- C. No part of the cord is encircling the baby's neck.
- D. The cord is still attached to the placenta.
Correct Answer: C
Rationale: Checking for a nuchal cord (cord around the neck) is critical to prevent compression, which could reduce blood flow and oxygen to the baby.
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.
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.
Newborns in nursery
A nurse receives handoff report. Which newborn should the nurse assess first?
- A. Glucose reading 58 mg/dL.
- B. Pulse 144 beats/minute.
- C. Respiratory rate 78 breaths/minute.
- D. Temperature 97.7° F (36.5° C).
Correct Answer: C
Rationale: A respiratory rate of 78 breaths/minute indicates tachypnea, suggesting potential respiratory distress, which requires immediate assessment.