Nokea
Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct Answer: A
Rationale: Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature. This can result in hypoglycemia and metabolic acidosis if not addressed. The use of a radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications.
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A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct Answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention.
A nurse is assessing a newborn who is 48 hr old and has a maternal history of methadone use during pregnancy. Which of the following manifestations should the nurse identify as an indication of neonatal abstinence syndrome?
- A. Hyporeactivity
- B. Excessive high-pitched cry
- C. Acrocyanosis
- D. Respiratory rate of 50/min
Correct Answer: B
Rationale: An excessive high-pitched cry is a classic sign of neonatal abstinence syndrome, indicating withdrawal from substances such as methadone. Other signs may include irritability and tremors.
A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?
- A. We will place the baby on its back to sleep
- B. We will give the baby a pacifier at bedtime
- C. We will keep the baby's crib free of blankets and toys
- D. We will leave the baby's diaper off to prevent diaper rash
Correct Answer: D
Rationale: Leaving a baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash.
A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?
- A. Fetal heart rate
- B. Client's blood pressure
- C. Client's respiratory rate
- D. Client's pain level
Correct Answer: B
Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being.
A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following is a factor strongly associated with this postpartum complication?
- A. Cesarean birth
- B. Vaginal birth
- C. Anemia
- D. Multiparity
Correct Answer: A
Rationale: Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors include smoking, obesity, and a history of thromboembolism.