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Following a vaginal delivery, the nurse places the neonate under the radiant warmer, provides naso-oropharyngeal suction, and dries the neonate's skin to elicit spontaneous respirations. The newborn heart rate is 100 beats/minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?
- A. Give blow-by oxygen via cannula.
- B. Start IV infusion in a scalp vein.
- C. Assist neonatologist with intubation.
- D. Provide positive pressure ventilation.
Correct Answer: D
Rationale: Positive pressure ventilation is critical for an apneic newborn to establish breathing and ensure oxygenation, per neonatal resuscitation guidelines.
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The healthcare provider prescribes magnesium sulfate 6 grams IV to be infused over 20 minutes for client with preterm labor. The IV bag contains 'Magnesium sulfate 20 grams in dextrose 5% in water 500 mL.' How many mL/hour should the nurse set the infusion pump?
- A. 450 mL/hour
Correct Answer: A
Rationale: For 6 grams in 20 minutes, 150 mL (6 ÷ 0.04 g/mL) is needed. Infusion rate is 150 mL ÷ 20 min × 60 = 450 mL/hour.
A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?
- A. Complete the assessment while allowing the child to cry.
- B. Explain to the child the reasons an examination is needed.
- C. Talk to the mother and gradually focus on the child's toy.
- D. Request extra staff to help with the nursing assessments.
Correct Answer: C
Rationale: Engaging the mother and using the child's toy as a distraction builds trust, reducing anxiety and encouraging cooperation.
A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled 'Isoniazid Oral Solution, USP 50 mg per 5 mL.' How many mL should the nurse administer?
- A. 25 mL
Correct Answer: A
Rationale: For a 25 kg child, the dose is 250 mg/day (25 kg × 10 mg/kg). With a concentration of 50 mg/5 mL (10 mg/mL), the volume is 250 mg ÷ 10 mg/mL = 25 mL.
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Administer antibiotics for 7 to 10 days.
- C. Give zidovudine 6 to 12 hours after birth.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: C
Rationale: Zidovudine within 6-12 hours reduces perinatal HIV transmission risk in newborns of HIV-positive mothers.
History and Physical
Nurses Notes
The client is a 4-year-old male with a history of prematurity, short gut syndrome, and liver and bowel transplant. He has been hospitalized for the past 8 months, 6 of those were spent in the pediatric intensive care unit. He is currently in the pediatric unit for observation as his post transplant medications are stabilized for discharge.
Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.
- A. Avoid mentioning anything about the mother to the child.
- B. Develop a trusting relationship with the child.
- C. Notify the mother that social services will be notified if she does not visit regularly.
- D. Have the child sign a treatment contract stating he will participate in therapy.
- E. Ask the mother to bring a familiar object from home.
- F. Facilitate phone conversations between the child and his mother.
Correct Answer: B,E,F
Rationale: Building trust, providing familiar objects, and facilitating mother-child communication support the child's emotional well-being during hospitalization.