Nokea
2-day-old newborn
The nurse explains to the parents of a 2-day-old newborn that decreased life span of neonatal red blood cells has contributed to which complication?
- A. Hyperbilirubinemia.
- B. Respiratory distress syndrome.
- C. Polycythemia.
- D. Transient tachypnea.
Correct Answer: A
Rationale: The increased breakdown of neonatal red blood cells, which have a shorter lifespan, produces bilirubin, leading to hyperbilirubinemia and potential jaundice.
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Newborn reflex observation
What reflex is elicited: Fanning of toes when stroking lateral edge of baby's foot?
- A. Babinski's Reflex.
- B. Stepping Reflex.
- C. Moro reflex.
- D. Plantar Grasp reflex.
Correct Answer: A
Rationale: Babinski's Reflex is elicited by fanning of the toes when the lateral edge of the foot is stroked, normal in infants up to 2 years.
Newborns in nursery
A nurse receives handoff report. Which newborn should the nurse assess first?
- A. Glucose reading 58 mg/dL.
- B. Pulse 144 beats/minute.
- C. Respiratory rate 78 breaths/minute.
- D. Temperature 97.7° F (36.5° C).
Correct Answer: C
Rationale: A respiratory rate of 78 breaths/minute indicates tachypnea, suggesting potential respiratory distress, which requires immediate assessment.
Vacuum extraction birth
While assisting with a vacuum extraction birth, what should the nurse immediately report to the physician?
- A. Maternal pulse rate of 100 bpm.
- B. Maternal blood pressure of 120/70 mm Hg.
- C. Decrease in intensity of uterine contractions.
- D. Persistent fetal bradycardia below 100 bpm.
Correct Answer: D
Rationale: Persistent fetal bradycardia below 100 bpm indicates potential fetal distress, requiring immediate reporting to ensure fetal safety.
Woman post-spinal anesthesia, pounding headache rated 7/10
A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?
- A. Place a cool cloth on her forehead and dim the room lights.
- B. Prepare to assist with a blood patch procedure.
- C. Increase the rate of her nonadditive IV fluids.
- D. Give the woman IV opioid pain medications.
Correct Answer: B
Rationale: A pounding headache post-spinal anesthesia suggests a spinal headache from cerebrospinal fluid leakage, best treated with a blood patch to seal the dural puncture.
Infant being weighed
The correct answer is choice A, which is to ensure that conductive heat loss from the infant is minimal
- A. ensure that conductive heat loss from the infant is minimal
- B. compensate for the negative weight balance to ensure the correct weight
- C. avoid causing multiple startle (Moro) reflexes when weighing
- D. avoid contaminating the nurse's hands with blood or other body substances
Correct Answer: A
Rationale: A covering on the scale tray minimizes conductive heat loss by preventing direct contact with the cold scale surface, critical for maintaining the infant's temperature.