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. Collect a urine specimen, Instruct the parent to feed the newborn, Place the Newborn under a phototherapy lamp, Admister penicilin IM
- B. Hypoglycemia, Congenital Syphilis,Kernicterus, Neonatal abstinence syndrome
- C. Balirubin Levels, Temperatures, Resipiratory Status, Environmental stimuli
Correct Answer:
Rationale:
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A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?
- A. Single palmar creases (p200
- B. Down Syndrome)
- C. Rust-stained urine
- D. Transient circumoral cyanosis
- E. Subconjunctival hemorrhage
Correct Answer: A
Rationale: The correct answer is A: Single palmar creases. This finding may indicate an increased risk for Down Syndrome. It is important to report this to the provider for further evaluation. Single palmar creases are less common and can be a marker for chromosomal abnormalities.
B: Down Syndrome is not a clinical finding but a diagnosis.
C: Rust-stained urine is not typically concerning in a newborn and may be due to uric acid crystals.
D: Transient circumoral cyanosis is common in newborns and usually resolves on its own.
E: Subconjunctival hemorrhage can occur during the birthing process and is usually benign.
A nurse is caring for a newborn who is 12 hr old and is experiencing jitteriness. Which of the following laboratory findings should the nurse identify as the priority?
- A. Blood glucose
- B. Total bilirubin
- C. Hemoglobin
- D. Blood calcium
Correct Answer: A
Rationale: The correct answer is A: Blood glucose. In a newborn experiencing jitteriness, the priority is to assess blood glucose levels to rule out hypoglycemia. Newborns are at risk for hypoglycemia due to limited glycogen stores and high metabolic demands. Untreated hypoglycemia can lead to serious complications like seizures and brain damage. Total bilirubin (choice B) is important for assessing jaundice but is not the priority in this case. Hemoglobin (choice C) and blood calcium (choice D) are not typically the first considerations for jitteriness in a newborn.
Which of the following is a potential complication of neonatal hypothermia?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Jaundice
- D. All of the above
Correct Answer: D
Rationale: All of the above are potential complications of neonatal hypothermia. Hypothermia can lead to hypoglycemia, respiratory distress, and jaundice due to the infant's inability to regulate body temperature.
Select the 5 actions the nurse should take
- A. Increase the flow rate of the maintenance IV fuid
- B. Have the charge nurse notify the provider
- C. Place the client in a Trendelenburg position
- D. Exert upward pressure on the presenting part.
- E. Attempt to push the umbilical cord back into the cervix
- F. Administer oxygen at 10 L/mm via nonrebreather face mask
Correct Answer: A,B,C,D,F
Rationale: A prolapsed umbilical cord is a life-threatening emergency requiring immediate intervention to relieve cord compression and restore fetal oxygenation. The priority actions are:
Notify the provider
Reposition the client (Trendelenburg or knee-chest)
Manually relieve pressure on the cord
Administer oxygen
Increase IV fluids for better circulation
A nurse is caring for a client who is in active labor with a fetus in the occipitoposterior position. The nurse assists the client into a hands-and-knees position. Which of the following questions should the nurse ask to evaluate the effectiveness of this intervention?
- A. Does that lessen your suprapubic pain?
- B. Are you feeling relief from your pelvic pressure?
- C. Do your contractions feel further apart?
- D. Has your back labor improved?
Correct Answer: D
Rationale: The correct answer is D: "Has your back labor improved?" This question is appropriate because the occipitoposterior position often leads to back labor due to the baby's position pressing on the mother's spine. By asking if the back labor has improved, the nurse can assess the effectiveness of the hands-and-knees position in helping relieve pressure on the mother's back.
Choice A: "Does that lessen your suprapubic pain?" is incorrect because the hands-and-knees position is more effective for back pain relief, not suprapubic pain.
Choice B: "Are you feeling relief from your pelvic pressure?" is incorrect because the hands-and-knees position is more effective for addressing back pain, not pelvic pressure.
Choice C: "Do your contractions feel further apart?" is incorrect as the position change is unlikely to affect the timing of contractions significantly.
In summary, the correct question (Choice D) directly addresses the main issue associated with occipitoposterior