Nokea
What is the priority for a newborn presenting with grunting and nasal flaring?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Start IV fluids to maintain hydration
- C. Position the newborn in a semi-Fowler's position
- D. Administer antibiotics to prevent infection
Correct Answer: A
Rationale: Administering oxygen helps improve oxygenation for a newborn in respiratory distress.
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The nurse is caring for a G5 in labor. The membrane
- A. Which nursing action is most important to undertake at this time?
- B. Complete sterile vaginal exam
- C. Assess odor of amniotic fluid
- D. Perform Leopold's maneuver
Correct Answer: A
Rationale: The most important nursing action to undertake at this time is obtaining a fetal heart rate (FHR) assessment. Monitoring the FHR is crucial during labor to assess the well-being of the baby and detect any signs of fetal distress. This information helps guide the healthcare team in determining the appropriate course of action to ensure the safety of both the mother and baby. It takes precedence over other tasks such as completing a sterile vaginal exam, assessing the odor of amniotic fluid, performing Leopold's maneuver, or obtaining pain medication orders. Monitoring the FHR should be the immediate priority in this situation.
A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
- A. Bulging Fontanels
- B. Nasal Flaring
- C. Length from head to heel of 40 cm (15.7 in)
- D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Correct Answer: D
Rationale: When a nurse is assessing a newborn upon admission to the nursery, it is expected that the chest circumference will be smaller than the head circumference. This is a normal finding in a newborn, where the head circumference is slightly larger than the chest circumference due to the proportionate sizes of the newborn's head and chest. This difference helps accommodate the vital organs within the chest cavity while allowing for the growth and development of the brain. Therefore, a chest circumference that is 2 cm smaller than the head circumference is a typical and expected finding in a newborn assessment.
A patient asks the nurse about using the basal body temperature method as contraception. What statement made by the patient indicates that the patient needs further teaching?
- A. “I need to take my temperature before I even sit up in bed.â€
- B. “A rise of 0.4° F above my baseline temperatures for 3 days indicates it is safe to have condomless sex.â€
- C. “I need to use a special thermometer to take my basal body temperature.â€
- D. “I know I am about to ovulate when my temperature rises at least 0.4° F.â€
Correct Answer: B
Rationale: Option B is the statement made by the patient that indicates the need for further teaching. In the basal body temperature method of contraception, a sustained temperature rise typically indicates ovulation has already occurred, making it unsafe to have condomless sex. It is the drop in temperature just before ovulation that is used to predict a fertile window. Therefore, a rise in temperature would not indicate that it is safe to have condomless sex. The patient should be educated that the temperature shift indicates the end of the fertile window and that it is safest to avoid unprotected sex during the fertile window.
The nurse is teaching a client about postpartum warning signs. Which symptom should be reported immediately?
- A. Increased lochia on standing.
- B. Breast tenderness and fullness.
- C. Severe headache and blurred vision.
- D. Mild swelling in the feet.
Correct Answer: C
Rationale: Severe headache and blurred vision may indicate postpartum complications such as preeclampsia.
The nurse is caring for a client with gestational diabetes. What fetal complication should the nurse monitor for after birth?
- A. Hyperglycemia.
- B. Macrosomia.
- C. Hypoglycemia.
- D. Hyperbilirubinemia.
Correct Answer: C
Rationale: Newborns of mothers with gestational diabetes are at risk for hypoglycemia due to high insulin levels after birth.