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The nurse is caring for a newborn who is 18 inches long, weighs 4 pounds, 14 ounces, has a head circumference of 13 inches, and a chest circumference of 10 inches. Based on these physical findings, assessment for which condition has the highest priority?
- A. Hyperthermia
- B. Hyperbilirubinemia
- C. Polycythemia
- D. Hypoglycemia
Correct Answer: D
Rationale: Small-for-gestational-age infants are at high risk for hypoglycemia (D).
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The nurse states to the newly pregnant patient, 'Tell me how you feel about being pregnant.' Which communication technique is the nurse using with this patient?
- A. Clarifying
- B. Paraphrasing
- C. Reflection
- D. Structuring
Correct Answer: A
Rationale: The nurse is attempting to follow up and check the accuracy of the patient's message, which is clarifying.
The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client?
- A. Administration of Pitocin
- B. Artificial rupture of the membrane
- C. Amnioinfusion for the baby
- D. Administration of antibiotics
Correct Answer: D
Rationale: Antibiotics (D) are administered to GBS+ mothers to prevent neonatal infection.
A pregnant patient with significant iron-deficiency anemia is prescribed iron supplements. The patient explains to the nurse that she cannot take iron because it makes her nauseous. What is the best response by the nurse?
- A. Iron will be absorbed more readily if taken with orange juice.'
- B. It is important to take this drug regardless of this side effect.'
- C. Taking the drug with milk may decrease your symptoms.'
- D. Try taking the iron at bedtime on an empty stomach.'
Correct Answer: D
Rationale: The correct answer is D: "Try taking the iron at bedtime on an empty stomach." Taking iron on an empty stomach at bedtime can help reduce nausea because there are fewer digestive interactions. Iron supplements are best absorbed on an empty stomach. Taking them with food or other beverages can worsen gastrointestinal side effects. Option A is incorrect as orange juice may increase the likelihood of nausea due to its acidity. Option B is incorrect as patient comfort and adherence are important considerations. Option C is incorrect as milk can decrease iron absorption.
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometer
- B. Review maternal medical records for blood type and Rh factor
- C. Prepare the newborn for phototherapy
- D. Evaluate cord results
Correct Answer: A
Rationale: Measuring bilirubin levels (A) is the first step to determine if phototherapy is necessary for jaundice.
A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What intervention should the nurse implement first?
- A. Raise the foot of the bed
- B. Assess for vaginal bleeding
- C. Evaluate the fetal heart rate
- D. Take the client's blood pressure
Correct Answer: A
Rationale: These symptoms are suggestive of hypotension which is a side effect of epidural anesthesia. Raising the foot of the bed (A) will increase venous return and provide blood to the vital areas. Increasing the IV fluid rate using a balanced non-dextrose solution and ensuring that the silent is in a lateral position are also appropriate interventions.