Nokea
What method of heat loss may occur if a newborn is placed on a cold scale or touch with cold hands:
- A. Conduction (occurs when the infant comes in contact with cold objects)
Correct Answer: A
Rationale: Conduction is the transfer of heat between objects that are in direct contact with each other. In the scenario where a newborn is placed on a cold scale or touched with cold hands, heat loss occurs through conduction. The cold temperature of the scale or hands will draw heat away from the infant's body, leading to a drop in body temperature. It is essential to ensure that newborns are not exposed to cold surfaces or objects for prolonged periods to prevent heat loss through conduction and maintain their body temperature within a safe range.
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A woman has been in labor for 16 hours. Her cervix is dilated
- A. The fetal presenting part is not engage
- B. The nurse would expect which malpresentation
- C. CPD (prevents presenting part form becoming engage
Correct Answer: A
Rationale: If a woman has been in labor for 16 hours and her cervix is not dilated, it suggests that the fetal presenting part is not engaged. Engagement refers to the descent of the fetal presenting part (usually the head) into the pelvis. When the presenting part is not engaged, it may lead to a prolonged labor as the fetus needs to descend further for labor to progress effectively. This can result in slower cervical dilation and may require interventions to help facilitate engagement, such as position changes or use of gravity-assisted techniques.
A client at 34 weeks' gestation is diagnosed with polyhydramnios. What is the nurse's priority assessment?
- A. Monitor maternal blood pressure.
- B. Assess for signs of preterm labor.
- C. Check for signs of infection.
- D. Evaluate for fetal heart rate changes.
Correct Answer: B
Rationale: Polyhydramnios increases the risk of preterm labor due to uterine overdistension, requiring close monitoring.
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.
A couple who has stated that they are LGBTQIA+ during prior visits arrives at the clinic for prenatal care. What can the nurse say in the waiting area to help them feel welcome and safe?
- A. You can take this tablet to an area in the waiting room and check in. Then bring the tablet back to me when you are done.
- B. Are you pregnant? Your paperwork says your name is Tom.
- C. You can have a seat, and a person from the LGBTQIA+ office will come to assist you.
- D. Here is our paperwork. It doesn't have a box for your sex, but you can write it next to the gender box.
Correct Answer: A
Rationale: Providing a neutral and respectful approach helps create a welcoming environment for LGBTQIA+ patients.
A nurse is caring for a newborn who is 6 hr. old and has a bedside glucometer reading of 65 mg/ dL. The newborn's mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to reassess the blood glucose level prior to the next feeding. A single low bedside glucometer reading is not sufficient to make treatment decisions, especially in a newborn who is only 6 hours old and with a mother having type 2 diabetes mellitus. It is important to follow up with another blood glucose measurement before taking further action. This will help ensure that appropriate interventions are taken based on accurate and reliable information.