Nokea
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.
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The nurse discovers that an African couple from Kenya has not named their 48-hour-old,full-term newborn and the infant and mother are being discharged to home. Which action should the nurse take in response to this information?
- A. Ask the parents to choose a name before discharge.
- B. Encourage other appropriate attachment behaviors.
- C. Document the discharge and that the baby is unnamed.
- D. Delay discharge until parental attachment is addressed.
Correct Answer: C
Rationale: In Kenyan culture naming may occur on the third day with celebration. Documenting the discharge and unnamed status is appropriate; naming isn’t required for attachment.
The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? Select all that apply.
- A. Have the mother nap before interacting with her newborn.
- B. Dim the lights in the birthing room.
- C. Place the newly delivered infant on the mother’s abdomen.
- D. Delay instilling the ophthalmic antibiotic for an hour.
- E. Play loud music to keep the infant stimulated.
- F. Ask the parents to delay phone calls for an hour after birth.
Correct Answer: B,C,D,F
Rationale: Dimming lights encourages eye contact skin-to-skin contact improves interaction delaying antibiotic ointment prevents blurred vision and delaying phone calls maximizes bonding time. Napping misses the alert period and loud music is overstimulating.
Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.
A 25 years old P2 comes to emergency,after home delivery with heavy bleeding per vaginum. After evaluation and emergency resuscitation she is diagnosed as a case of uterine atony. What is the appropriate medicine in the management of this case:
- A. Oxytocin.
- B. Salbutamol.
- C. Beta blockers.
- D. Magnesium sulphate.
- E. Hydralazine.
Correct Answer: A
Rationale: Oxytocin is the first-line treatment for uterine atony as it stimulates uterine contractions to control postpartum hemorrhage. Other options are not indicated for this condition.
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.