Nokea
The nurse is caring for a newly delivered breast-feeding infant. Which nursing intervention would best prevent jaundice in this infant?
- A. Encouraging the mother to supplement breast-feeding with formula.
- B. Keeping the infant NPO until the second period of reactivity.
- C. Encouraging the mother to breastfeed the infant every 2 to 3 hours.
- D. Placing the infant under phototherapy.
Correct Answer: C
Rationale: The correct answer is C: Encouraging the mother to breastfeed the infant every 2 to 3 hours. Breastfeeding frequently helps prevent jaundice by promoting the excretion of bilirubin through stool. This helps prevent bilirubin buildup in the baby's body, reducing the risk of jaundice. Encouraging frequent breastfeeding also ensures the infant receives adequate hydration, which aids in the elimination of bilirubin.
Choice A is incorrect because supplementing with formula can interfere with breastfeeding and affect bilirubin excretion. Choice B is incorrect because keeping the infant NPO can lead to dehydration and decreased bilirubin excretion. Choice D is incorrect because phototherapy is a treatment for jaundice, not prevention.
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A nurse on the obstetric unit is caring for a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize that this client is at risk for which of the following complications?
- A. Preeclampsia
- B. Puerperal infection
- C. Anaphylactoid syndrome of pregnancy
- D. Disseminated intravascular coagulation
Correct Answer: D
Rationale: The correct answer is D: Disseminated intravascular coagulation (DIC). Abruptio placentae can lead to DIC due to the release of tissue factor, causing widespread clotting and consumption of clotting factors, leading to bleeding. Petechiae and bleeding around the IV site are signs of DIC. Preeclampsia (choice A) is a condition characterized by hypertension and proteinuria. Puerperal infection (choice B) is an infection that occurs after childbirth. Anaphylactoid syndrome of pregnancy (choice C) is a rare complication associated with amniotic fluid embolism. These complications are not directly related to the signs and symptoms described in the scenario.
A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following interventions should the nurse include in the plan of care?
- A. Monitor blood glucose levels.
- B. Monitor intake and output.
- C. Monitor weight.
- D. Monitor axillary temperature.
Correct Answer: A
Rationale: Correct Answer: A - Monitor blood glucose levels.
Rationale: Small for gestational age (SGA) newborns are at risk for hypoglycemia due to decreased glycogen stores. Monitoring blood glucose levels is crucial to detect and manage hypoglycemia promptly. This intervention ensures early intervention to prevent complications.
Incorrect Choices:
B: Monitoring intake and output is important for overall assessment but not specific to SGA newborns.
C: Monitoring weight is important for growth assessment but does not directly address the immediate risk of hypoglycemia in SGA newborns.
D: Monitoring axillary temperature is important for assessing newborn's thermoregulation but does not address the specific risk of hypoglycemia in SGA newborns.
A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?
- A. Increase in lochia.
- B. Report of absent breast pain.
- C. Increase in blood pressure.
- D. Fundus firm to palpation.
Correct Answer: D
Rationale: The correct answer is D: Fundus firm to palpation. Methylergonovine is a medication used to prevent or treat postpartum hemorrhage by promoting uterine contractions. When the fundus is firm to palpation, it indicates that the uterus is contracting effectively, which helps prevent excessive bleeding.
Explanation for incorrect choices:
A: Increase in lochia is not an indicator of methylergonovine effectiveness.
B: Absent breast pain is not related to the effectiveness of methylergonovine.
C: Increase in blood pressure is not a typical response to methylergonovine.
D: Fundus firm to palpation is the correct response.
E-G: No additional choices provided.
A client is being treated with magnesium sulfate IV. The client’s respiratory rate is 10/min. What should the nurse do?
- A. Assess maternal blood glucose.
- B. Discontinue the magnesium infusion.
- C. Prepare for an emergency cesarean birth.
- D. Place the client in Trendelenburg position.
Correct Answer: B
Rationale: Correct Answer: B - Discontinue the magnesium infusion.
Rationale: A respiratory rate of 10/min indicates respiratory depression, a common adverse effect of magnesium sulfate. Discontinuing the infusion is crucial to prevent further respiratory compromise and potential respiratory arrest. This action takes precedence over other interventions as it addresses the immediate risk to the client's safety.
Summary of other choices:
A: Assessing maternal blood glucose is unrelated to the client's respiratory rate and immediate need for intervention.
C: Emergency cesarean birth is not indicated based solely on the respiratory rate and magnesium sulfate administration.
D: Placing the client in Trendelenburg position is not appropriate for respiratory depression and may worsen the situation.
A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?
- A. Drying the newborn’s skin thoroughly.
- B. Preventing air drafts.
- C. Placing the newborn on a warm surface.
- D. Maintaining ambient room temperature at 24°C (75.2°F).
Correct Answer: A
Rationale: The correct answer is A: Drying the newborn's skin thoroughly. When a newborn is born, they are wet and evaporative heat loss occurs as the moisture on their skin evaporates, leading to cooling. Drying the newborn's skin thoroughly helps reduce this heat loss by preventing the moisture from evaporating. Preventing air drafts (B) and placing the newborn on a warm surface (C) can help with overall thermal regulation but do not specifically target evaporative heat loss. Maintaining ambient room temperature at 24°C (75.2°F) (D) is important for thermoregulation but does not directly address evaporative heat loss.