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A nurse is planning care immediately following birth for a newborn who has myelomeningocele that is leaking cerebrospinal fluid.
- A. Administer broad-spectrum antibiotics
- B. Cleans the site with povidone-iodine
- C. Monitor the rectal temperature every 4 hours
- D. Prepare for surgical closure after 72 hours
Correct Answer: A
Rationale: The correct answer is A. Administering broad-spectrum antibiotics is crucial to prevent infection since the exposed spinal cord increases the risk. Antibiotics help reduce the risk of meningitis and sepsis. Choice B is incorrect as povidone-iodine can be irritating to the sensitive skin around the defect. Choice C is incorrect as monitoring rectal temperature is not directly related to the immediate care needed for a myelomeningocele. Choice D is incorrect because surgical closure should be done as soon as possible to prevent further complications.
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A client who is 16 weeks of gestation asks the nurse how to prepare her toddler for a younger sibling.
- A. You should hold your newborn in your arms when you introduce him to your toddler
- B. You should move your toddler out of her crib 2 weeks prior to your due date
- C. You should place your toddler in timeout if she exhibits regressive Behavior after the baby is born
- D. You should place your toddler in timeout if she exhibits regressive behavior after the baby is born
Correct Answer: B
Rationale: The correct answer is B because moving the toddler out of the crib before the baby arrives allows the toddler time to adjust to the change without associating it directly with the baby's arrival. Holding the newborn in your arms (A) may make the toddler feel left out. Placing the toddler in timeout (C, D) for regressive behavior can create negative associations with the new sibling.
A nurse is planning care for a newborn who has neonatal abstinence syndrome. Which of the following interventions should the nurse include in the plan of care?
- A. Increase the newborn’s visual stimulation
- B. Weigh the newborn every other day
- C. Discourage parental interaction until after a social evaluation
- D. Swaddle the newborn in a flexed position
Correct Answer: D
Rationale: The correct answer is D: Swaddle the newborn in a flexed position. This intervention helps provide comfort and security to the newborn, which can help reduce symptoms of neonatal abstinence syndrome. Swaddling in a flexed position mimics the womb environment, promoting relaxation and reducing irritability.
A: Increasing visual stimulation can overwhelm the newborn and exacerbate symptoms.
B: Weighing the newborn every other day is not directly related to managing neonatal abstinence syndrome.
C: Discouraging parental interaction can hinder bonding and support, which are crucial for the newborn's well-being.
A nurse is assessing a newborn upon admission to the nursery. Which of the following should the nurse expect?
- A. Bulging Fontanels
- B. Nasal Flaring
- C. Length from head to heel of 40 cm (15.7 in)
- D. Chest circumference 2 cm (0.8 in) smaller than the head circumference
Correct Answer: D
Rationale: The correct answer is D because a chest circumference smaller than the head circumference is a normal finding in a newborn due to the larger head size compared to the chest. This is known as head sparing and is essential for brain development. Bulging fontanels (choice A) are abnormal and may indicate increased intracranial pressure. Nasal flaring (choice B) is a sign of respiratory distress. A length of 40 cm (choice C) is within the average range but not a specific expectation upon admission. Therefore, choice D is the most appropriate expectation for a newborn assessment.
A nurse is planning care for a full-term newborn who is receiving phototherapy. Which of the following actions should the nurse include in the plan of care?
- A. Dress the newborn in lightweight clothing.
- B. Avoid using lotion or ointment on the newborn skin.
- C. Keep the newborn supine throughout treatment
- D. Measure the newborn’s temperature every 8hr
Correct Answer: B
Rationale: The correct answer is B: Avoid using lotion or ointment on the newborn skin. This is because lotions or ointments can interfere with the effectiveness of phototherapy by blocking the light from reaching the skin. Dressing the newborn in lightweight clothing (Choice A) is important to maximize skin exposure to the light. Keeping the newborn supine throughout treatment (Choice C) is not directly related to the effectiveness of phototherapy. Measuring the newborn's temperature every 8 hours (Choice D) is important but not specifically related to phototherapy.
A nurse is caring for a newborn who is 6 hr old and has a bedside glucometer reading of 65 mg/ dL. The newborn’s mother has type 2 diabetes mellitus. Which of the following actions should the nurse take?
- A. Obtain a blood sample for a serum glucose level
- B. Feed the newborn immediately
- C. Administer 50 mL of dextrose solution IV
- D. Reassess the blood glucose level prior to the next feeding
Correct Answer: B
Rationale: The correct answer is B: Feed the newborn immediately. In this scenario, the newborn's low blood glucose level may be due to inadequate glycogen stores from the mother's diabetes. Feeding the newborn will help increase their blood glucose levels naturally. Other choices are incorrect because: A: Obtaining a blood sample for a serum glucose level delays immediate action. C: Administering dextrose solution IV is an invasive intervention that should be reserved for severe cases. D: Reassessing the blood glucose level is important but should not delay feeding in this critical situation. E, F, G: No information given.