Nokea
The nurse is admitting a neonate after delivery who is diagnosed with a myelomeningocele. Which intervention should the nurse implement immediately?
- A. Positions the infant prone and covers the sac with sterile gauze.
- B. Notifies the surgeon on call that the infant is ready for surgery.
- C. Applies a pressure dressing to the sac and starts an intravenous access.
- D. Positions the infant prone,hips slightly flexed and legs abducted.
Correct Answer: D
Rationale: Positioning prone with hips flexed and legs abducted minimizes sac tension and rupture risk. Sterile gauze risks adherence surgery follows stabilization and pressure dressings risk rupture.
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The nurse is caring for the client who has just given birth to a baby boy. The mother is O negative. The nurse should assess for ABO incompatibility and hyperbilirubinemia if the infant’s blood type is which type?
- A. O positive
- B. O negative
- C. A negative
- D. Any type
Correct Answer: C
Rationale: ABO incompatibility occurs when a mother with type O blood (no antigens A/B antibodies) has an infant with A or B blood (e.g. A negative) leading to hemolysis and hyperbilirubinemia. O blood types are compatible.
The nurse receives a laboratory report result showing that the blood glucose is 48 mg/dL for a full-term newborn. Which action should be taken by the nurse?
- A. Have the mother breastfeed her newborn now.
- B. Immediately feed the infant water with 10% dextrose.
- C. Report the results immediately to the health care provider.
- D. Document the information in the newborn’s medical record.
Correct Answer: D
Rationale: Normal blood sugar values for a full-term newborn are 45–65 mg/dL. A value of 48 mg/dL is normal so the only action required is documentation. Feeding or reporting is unnecessary.
. A new mother of a full-term, 7-lb newborn asks the nurse how to ensure that her baby is taking the correct amount of formula at each feeding. The nurse explains that the infant needs approximately 3 ounces of fluid per pound of body weight per day. How many ounces of formula should her infant be eating every 4 hours? _________ ounces (Record your answer to the nearest tenth.)
Correct Answer: 3.5
Rationale: Multiplying 3 oz by 7 lb = 21 oz/day. Dividing 21 oz by 6 feedings (every 4 hours) = 3.5 oz per feeding.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
The nurse evaluates a preterm infant after a gavage feeding. The nurse determines that feeding intolerance has developed when which finding is noted during assessment?
- A. The infant immediately falls asleep after feeding.
- B. The gastric residual is zero prior to the next feeding.
- C. The infant’s abdominal girth has increased in size.
- D. The infant is having soft,loose stools.
Correct Answer: C
Rationale: Increased abdominal girth indicates feeding intolerance suggesting issues like paralytic ileus or NEC. Sleeping zero residual and loose stools are normal.