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At a home visit, the nurse assesses a neonate delivered vaginally at 41 weeks' gestation 5 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin; which of these findings warrants further assessment?
- A. Frequent hiccups.
- B. Loose, watery stool in diaper.
- C. Pink papular vesicles on the face.
- D. Dry, peeling skin.
Correct Answer: B
Rationale: Loose, watery stool may indicate diarrhea, which requires further assessment to rule out infection or malabsorption.
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During a scheduled cesarean delivery of a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean delivery tend to have an increased incidence of which of the following?
- A. Congenital anomalies.
- B. Pulmonary hypertension.
- C. Meconium aspiration syndrome.
- D. Respiratory distress syndrome.
Correct Answer: D
Rationale: Cesarean delivery, especially without labor, increases the risk of respiratory distress syndrome due to retained lung fluid. Breech presentation may exacerbate this. Congenital anomalies, pulmonary hypertension, and meconium aspiration are less directly related.
A primigravida is admitted to the labor area with ruptured membranes and contractions occurring every 2 to 3 minutes, lasting 45 seconds. After 3 hours of labor, the client's contractions are now every 7 to 10 minutes, lasting 30 seconds. The nurse administers oxytocin (Pitocin) as ordered. The expected outcome of this drug is:
- A. The cervix will begin to dilate 2 centimeters per hour.
- B. Contractions will occur every 2 to 3 minutes, lasting 40 to 60 seconds, moderate intensity, resting tone between contractions.
- C. The cervix will change from firm to soft, efface to 40% to 50%, and move from a posterior to anterior position.
- D. Contractions will be every 2 minutes, lasting 60 to 90 seconds, with intrauterine pressure of 70 mm Hg.
Correct Answer: B
Rationale: Oxytocin is used to augment labor by increasing contraction frequency, duration, and intensity. The expected outcome is regular contractions every 2–3 minutes, lasting 40–60 seconds, with moderate intensity and adequate resting tone, promoting effective labor progression. The other options describe unrealistic or unrelated effects.
Which of the following instructions should the nurse give to the parents of a neonate diagnosed with hyperbilirubinemia who is receiving phototherapy?
- A. Keep the neonate's eyes completely covered.
- B. Use a regular diaper on the neonate.
- C. Offer feedings every 4 hours.
- D. Check the oral temperature every 8 hours.
Correct Answer: A
Rationale: Keeping the neonate's eyes completely covered protects them from potential retinal damage during phototherapy.
A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which of the following?
- A. An immature cardiac sphincter.
- B. A defect in the gastrointestinal system.
- C. Burping the infant too frequently.
- D. Moving the infant during the feeding.
Correct Answer: A
Rationale: An immature cardiac sphincter in newborns can cause regurgitation of formula.
Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breast-feeding?
- A. Breast milk quality and richness are decreased.
- B. The mother's motivation to breast-feed is diminished.
- C. Medications may be excreted in breast milk to the nursing neonate.
- D. Medications interfere with the mother's letdown reflex.
Correct Answer: C
Rationale: Medications can pass into breast milk, potentially affecting the neonate, making this the primary concern.