Nokea
Immediately after birth, the nurse places the newborn under a radiant warmer. Which is the primary rationale for the nurse's action?
- A. To facilitate an efficient means of thermoregulation
- B. To facilitate initial assessment by the nurse
- C. To permit the use of the cardiac monitor
- D. To permit close observation by the family members
Correct Answer: A
Rationale: The correct answer is A: To facilitate an efficient means of thermoregulation. Placing the newborn under a radiant warmer helps prevent hypothermia by maintaining the baby's body temperature. Newborns have difficulty regulating their own body temperature initially, so the radiant warmer provides a controlled environment to keep them warm. Choice B is incorrect because the primary reason is not for assessment but for thermoregulation. Choice C is incorrect as a cardiac monitor is not typically needed immediately after birth. Choice D is incorrect as the primary focus is on the newborn's well-being, not family observation.
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If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive?
- A. Metformin (Glucophage)
- B. Glucagon
- C. Insulin
- D. Glyburide (DiaBeta)
Correct Answer: C
Rationale: The correct answer is C: Insulin. Insulin is the preferred medication for managing gestational diabetes as it is safe for the fetus and provides precise blood sugar control. Metformin (A) and Glyburide (D) are alternatives if insulin is not tolerated, but they may cross the placenta and have potential risks. Glucagon (B) is not used for diabetes management but for treating severe hypoglycemia.
A nurse is assessing a newborn following a circumcision. Which of the following should the nurse identify as an indication that the newborn is experiencing pain?
- A. Decreased heart rate
- B. Chin quivering
- C. Pinpoint pupils
- D. Slowed respirations
Correct Answer: B
Rationale: The correct answer is B: Chin quivering. This is a common sign of pain in newborns as they may not be able to communicate verbally. It indicates distress and discomfort. Decreased heart rate (A) and pinpoint pupils (C) are not indicative of pain but rather can be signs of other medical conditions. Slowed respirations (D) can be a sign of distress but not specifically pain. Therefore, B is the most relevant and specific indicator of pain in this scenario.
A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestation for which the nurse should monitor?
- A. Anaphylaxis
- B. Cerebral edema
- C. Impaired coagulation
- D. Hypervolemia
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. In Reye syndrome, cerebral edema is the most serious manifestation due to increased intracranial pressure, potentially leading to brain damage or death. Anaphylaxis (A) is not typically associated with Reye syndrome. Impaired coagulation (C) can occur but is not as immediately life-threatening as cerebral edema. Hypervolemia (D) is a possible complication but not as critical as cerebral edema in Reye syndrome.
A client delivered two days ago and is suspected of having postpartum 'blues.' Which symptoms confirm the diagnosis?
- A. Uncontrollable crying and insecurity
- B. Depression and suicidal thoughts
- C. Sense of the inability to care for the family and extreme anxiety
- D. Nausea and vomiting
Correct Answer: A
Rationale: The correct answer is A because uncontrollable crying and insecurity are classic symptoms of postpartum blues, also known as baby blues. This condition is characterized by mood swings, tearfulness, and feelings of vulnerability. Choices B, C, and D are incorrect as they suggest more severe symptoms associated with postpartum depression or other mental health disorders, which require immediate intervention. Nausea and vomiting (choice D) are not typically associated with postpartum blues. It is essential to differentiate between postpartum blues and more serious conditions to provide appropriate support and treatment to the client.
A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10.
- A. "Continue with the pain assessment."'
- B. "Take the child's vital signs."'
- C. "Notify the primary care provider."'
- D. "Auscultate the child's bowel sounds."'
Correct Answer: C
Rationale: The correct answer is C, "Notify the primary care provider." This is because a pain rating of 8 in a child with appendicitis indicates severe pain that may require immediate medical intervention. The primary care provider should be informed promptly to assess the situation and determine the appropriate course of action, which may include pain management or surgical intervention. Taking vital signs (choice B) and auscultating bowel sounds (choice D) are important assessments but do not address the urgency of the situation. Continuing with the pain assessment (choice A) may delay necessary interventions.