Nokea
The nurse finds documentation in the 4-hour-old newborn’s medical record that states,“Clamping of the umbilical cord was delayed until cord pulsations ceased.” When assessing and collecting additional information about the newborn,what effect should the nurse find as a result of the delayed cord clamping?
- A. More rapid expulsion of meconium by the newborn
- B. Increased level of newborn alertness after birth
- C. An increase in the newborn’s initial temperature
- D. An increase in the newborn’s hemoglobin and hematocrit
Correct Answer: D
Rationale: Newborn Hgb and Hct values will be higher when placental transfusion accomplished through delayed cord clamping occurs at birth. Blood volume increases by up to 50% with delayed cord clamping. Meconium passage alertness and temperature are not affected by delayed clamping.
You may also like to solve these questions
The nurse assesses that the 8-hour-old infant’s axillary temperature is 97°F (36.1°C). Which intervention should the nurse implement first?
- A. Document the findings as abnormal.
- B. Place the infant under a radiant warmer.
- C. Feed the infant formula that is warmed.
- D. Call the HCP to report the temperature.
Correct Answer: B
Rationale: An axillary temperature of 97°F is below the normal range (97.7°F–98.9°F). The infant should be gradually rewarmed under a radiant warmer. Documentation follows intervention feeding warm formula is unnecessary and HCP notification is needed only if warming fails.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
Which statement by the client indicates a need for additional teaching about genital herpes?
- A. Males who have genital herpes need a yearly prostate-specific antigen (PSA) test.
- B. Females who have genital herpes need a Papanicolaou (Pap) test every 6 months.
- C. Genital herpes is closely associated with the occurrence of sterility.
- D. Genital herpes is closely associated with Hodgkin's disease.
Correct Answer: A
Rationale: Genital herpes is not associated with a need for yearly PSA tests in males, indicating a misconception. Regular Pap tests may be recommended for females due to increased cervical cancer risk with certain STIs, but the PSA statement is incorrect.
Which response by the nurse provides the best clarification about the disease process?
- A. If you're afraid of getting HIV, you'll be safer if you avoid having sex with past sex partners.
- B. An HIV-positive individual may not develop symptoms of AIDS for years.
- C. HIV can only be transmitted when symptoms of AIDS are present.
- D. The medication prescribed for AIDS also protects against HIV infection.
Correct Answer: B
Rationale: HIV can be asymptomatic for years, during which it is still transmissible, making this clarification critical for understanding the disease process and transmission risk.
What information regarding the dangers of tattooing should the nurse provide for this client? Select all that apply.
- A. Tattooing can lead to skin cancer.
- B. There can be an allergic reaction to the tattoo ink.
- C. Tattooing can result in skin infections.
- D. There is a risk for contracting hepatitis B and human immunodeficiency virus (HIV) if dirty needles are used in tattooing.
- E. Tattooing can cause spontaneous abortions in pregnant women.
- F. Tattooing can result in heart and lung conditions.
Correct Answer: B,C,D
Rationale: Tattooing risks include allergic reactions to ink, skin infections from unsterile equipment, and bloodborne infections like hepatitis B and HIV from contaminated needles. Skin cancer, abortions, and heart/lung conditions are not directly linked.