Nokea
History and Physical:
Nurses' Notes:
Vital Signs
The neonate was born vaginally at 0130 to a 32-year-old gravida 3, para 3, abortion 0 (G3P3A0) mother. The neonate was born at 39 weeks gestation. The mother had an uncomplicated pregnancy and delivery.
The nurse evaluates the data presented. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Potential Conditions: Altered respiratory function, Hypoglycemia, Thermoregulation, Sepsis, Hyperbilirubinemia
- B. Actions: Provide manual breaths with a bag-valve mask (BVM), Give dextrose solution orally, Administer intravenous (IV) antibiotics, Place the neonate under a radiant warmer, Perform a heel stick for blood glucose testing
- C. Parameters: Respiratory rate, Temperature, Blood glucose levels, Oxygen saturation, Bilirubin levels
Correct Answer: B,E,C
Rationale: Hypoglycemia is likely due to jitteriness and low temperature; oral dextrose and heel stick glucose testing address it, while monitoring glucose levels and temperature tracks progress.
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History and Physical:
Nurses' Notes
Flow Sheet
The client is a 26-year-old female gravida 2, para 1, term 1, living 1. She was admitted to the labor and delivery unit with cervical dilation of 4 cm, 70% effacement, and -1 station. Her pregnancy has been uncomplicated, and she has no significant medical history.
A nurse is caring for a 26-year-old female client in the labor and delivery unit. The client is gravida 2, para 1, term 1, living 1, and is admitted with cervical dilation of 4 cm, 70% effacement, and -1 station. The pregnancy has been uncomplicated.
The nurse reviews the client data. Drag the word choices to complete the sentence. Abnormal FHR patterns can result in [Dropdown Group 1], [Dropdown Group 2], and [Dropdown Group 3].
- A. Acidemia.
- B. Hypoxemia.
- C. Hypoxia.
- D. Meconium stool.
- E. Maternal hypotension.
- F. Hypoglycemia.
Correct Answer: A,B,C
Rationale: Abnormal FHR patterns indicate acidemia (low pH), hypoxemia (low blood oxygen), and hypoxia (tissue oxygen deficiency), directly affecting fetal oxygenation.
Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?
- A. Obtain a heel stick blood glucose level.
- B. Document the findings in the record.
- C. Swaddle the infant in a warm blanket.
- D. Place a pulse oximeter on the heel.
Correct Answer: A
Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia; a heel stick glucose test is critical for confirmation and prompt treatment.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment is the standard prophylaxis for ophthalmia neonatorum caused by Neisseria gonorrhoeae, preventing severe eye infections.
The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?
- A. Administer a PRN dose of acetaminophen.
- B. Assess perineum for excessive lochia.
- C. Document the vital signs in the record.
- D. Report heart rate to healthcare provider.
Correct Answer: C
Rationale: These vital signs are normal postpartum; documenting them ensures accurate tracking without unnecessary interventions.
The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?
- A. Improve insufficient dietary intake.
- B. Stimulate the immune system.
- C. Prevent hemorrhagic disorders.
- D. Help an immature liver.
Correct Answer: C
Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.