Nokea
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale: Action to Take: A, B; Potential Condition: B; Parameter to Monitor: C, E.
Rationale:
The correct actions to take are to place newborn skin to skin on birthing parent's chest and encourage breastfeeding, as these promote bonding and breastfeeding, crucial for newborn well-being. The potential condition the client is most likely experiencing is Cold stress, indicated by the need for phototherapy. The parameters to monitor are Temperature (to track for hypothermia due to cold stress) and Bilirubin level (to assess for jaundice, common in newborns with cold stress).
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Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify it the intervention is indicated or contraindicated for the client.
- A. Insert a large bore intravenous catheter.
- B. Assess cervical dilation.
- C. Weigh perineal pads.
- D. Administer methotrexate.
Correct Answer: A, C
Rationale: Inserting a large bore IV catheter is indicated to manage potential hemorrhage. Weighing perineal pads helps quantify blood loss. Assessing cervical dilation is contraindicated as it may exacerbate bleeding. Administering methotrexate is not relevant in this context.
A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?
- A. Lays the newborn across their lap and gently sways.
- B. Places the newborn in the crib in a prone position.
- C. Offers the newborn a pacifier dipped in formula.
- D. Prepares a bottle of formula mixed with rice cereal.
Correct Answer: A
Rationale: Laying the newborn across the lap and gently swaying is a positive parenting behavior that can help soothe the newborn and promote bonding.
A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?
- A. Large for gestational age
- B. Hyperglycemia
- C. Bradypnea
- D. Vomiting
Correct Answer: C, D
Rationale: The correct manifestations of SSRI withdrawal in a newborn are bradypnea (C) and vomiting (D). SSRI use during pregnancy can lead to neonatal withdrawal symptoms due to drug exposure in utero. Bradypnea is a common withdrawal symptom characterized by slow breathing rate in newborns. Vomiting is another withdrawal symptom that can occur in newborns exposed to SSRIs. Large for gestational age (A) and hyperglycemia (B) are not typical manifestations of SSRI withdrawal. Therefore, the nurse should focus on monitoring for bradypnea and vomiting as signs of SSRI withdrawal in the newborn.
Which of the following is a potential complication of meconium aspiration syndrome?
- A. Respiratory distress syndrome
- B. Hypoglycemia
- C. Jaundice
- D. All of the above
Correct Answer: A
Rationale: The correct answer is A: Respiratory distress syndrome. Meconium aspiration can lead to airway obstruction, inflammation, and surfactant dysfunction, resulting in respiratory distress syndrome. Hypoglycemia and jaundice are not directly associated with meconium aspiration syndrome. Therefore, choice A is the most appropriate complication.
Which of the following is a potential complication of a postpartum hemorrhage?
- A. Hypertension
- B. Anemia
- C. Thrombocytopenia
- D. All of the above
Correct Answer: B
Rationale: The correct answer is B: Anemia. Postpartum hemorrhage can lead to excessive blood loss, causing a drop in red blood cell count and hemoglobin levels, resulting in anemia. Hypertension is not a typical complication of postpartum hemorrhage, as it is more commonly associated with conditions like preeclampsia. Thrombocytopenia, a low platelet count, may occur in severe cases of postpartum hemorrhage but is not a common complication compared to anemia. Choice D, "All of the above," is incorrect as only anemia is a direct potential complication of postpartum hemorrhage.