Nokea
The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?
- A. Perform a gestational age assessment.
- B. Obtain a drug screen for cocaine.
- C. Determine reactivity of neonatal reflexes.
- D. Weigh and measure the newborn.
Correct Answer: B
Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.
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A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
- A. Suction the oral and nasal passages.
- B. Give oxygen by positive pressure.
- C. Stimulate the infant to cry.
- D. Turn the infant onto the right side.
Correct Answer: A
Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.
What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula?
- A. Body temperature.
- B. Level of pain.
- C. Time of first void.
- D. Number of vessels in the cord.
Correct Answer: D
Rationale: The priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula is to check the number of vessels in the cord. This assessment is crucial to identify any potential anomalies related to the TE fistula, as abnormalities in the cord vessels may indicate associated congenital anomalies that need immediate attention.
During an examination for possible cryptorchidism in an infant, what technique should be used?
- A. Place the infant in a warm room and use a calm approach.
- B. Hold the scrotum and palpate gently.
- C. Cleanse the penis with an antiseptic-soaked pad.
- D. Position the infant in a warm room to prevent muscle contraction.
Correct Answer: D
Rationale: When examining an infant for cryptorchidism, it is important to position the infant in a warm room to prevent muscle contraction, which could cause the testes to retract. Placing the infant in a side-lying position may not be necessary for this specific examination. Holding the penis or retracting the foreskin is not relevant to the assessment for cryptorchidism. Cleansing the penis with an antiseptic pad is not indicated for this examination.
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a 'V' shaped appearance. What action should the nurse take first?
- A. Change the maternal position.
- B. Administer oxygen at 10 L by mask.
- C. Prepare for a potential cesarean.
- D. Allow the client to begin pushing.
Correct Answer: A
Rationale: In cases of fetal heart rate patterns showing abrupt falls and rises with a 'V' shaped appearance, it indicates possible cord compression. Changing the maternal position, such as moving the mother onto her side, can relieve the pressure off the cord and help improve fetal oxygenation, making it the priority intervention to address the decelerations.
An expectant father tells the LPN/LVN he fears that his wife 'is losing her mind.' He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father?
- A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse.
- B. Help him understand that his wife is experiencing normal maternal behaviors and bonding with the baby, and reassure him that these actions are positive.
- C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit.
- D. Let him know that these behaviors are part of normal maternal-fetal bonding which occur once the mother feels fetal movement.
Correct Answer: D
Rationale: The father's concerns about his wife's behaviors can be addressed by explaining that behaviors like talking to the baby and responding to fetal movements are part of normal maternal-fetal bonding. These actions indicate that the mother is connecting with the baby and are positive signs of a healthy pregnancy. The nurse should reassure the father that these behaviors are common and beneficial for the mother-baby relationship during pregnancy.