Nokea
As the nurse prepares to administer prophylactic eye treatment to prevent gonorrheal conjunctivitis in the full-term newborn,the newborn’s father asks if it is really necessary to put something into his baby’s eyes. Which statement should be the basis for the nurse’s response?
- A. It is the law in the United States that newborns receive this prophylactic treatment.
- B. This treatment is recommended but may be omitted at the parent’s verbal request.
- C. The antibiotic used for the treatment can be given orally at the parent’s request.
- D. The eye prophylaxis can be given anytime up until the infant is 1 year old.
Correct Answer: A
Rationale: Currently every U.S. state requires that newborns receive prophylactic eye treatment against gonorrheal conjunctivitis. Refusal requires formal documentation the antibiotic is topical only and prophylaxis must be given within 1 hour of birth.
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The nurse finds documentation in the 4-hour-old newborn’s medical record that states,“Clamping of the umbilical cord was delayed until cord pulsations ceased.” When assessing and collecting additional information about the newborn,what effect should the nurse find as a result of the delayed cord clamping?
- A. More rapid expulsion of meconium by the newborn
- B. Increased level of newborn alertness after birth
- C. An increase in the newborn’s initial temperature
- D. An increase in the newborn’s hemoglobin and hematocrit
Correct Answer: D
Rationale: Newborn Hgb and Hct values will be higher when placental transfusion accomplished through delayed cord clamping occurs at birth. Blood volume increases by up to 50% with delayed cord clamping. Meconium passage alertness and temperature are not affected by delayed clamping.
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
Total bishops score is:
- A. 10
- B. 8
- C. 6
- D. 4
- E. 13
Correct Answer: E
Rationale: The Bishop score assesses cervical readiness for labor with a maximum of 13 points (dilation effacement station consistency position). Higher scores indicate better inducibility.
The nurse is reviewing the following labor history of a postpartum mother: “Mother positive for group B streptococcal (GBS) infection at 37 weeks’ gestation. Membranes ruptured at home 14 hours before presentation to the hospital at 40 weeks’ gestation. Precipitous labor,no antibiotic given.” Considering this information the nurse should observe her 15-hour-old newborn closely for which finding?
- A. Temperature instability
- B. Pink stains in the diaper
- C. Meconium stools
- D. Presence of erythema toxicum
Correct Answer: A
Rationale: GBS infection risk increases with prolonged membrane rupture and no antibiotics with temperature instability as an early symptom. Pink stains meconium and erythema toxicum are normal.
Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.