Nokea
The nurse is monitoring a client in labor. What finding indicates the transition phase?
- A. Cervix dilated to 4 cm.
- B. Cervix dilated to 8 cm.
- C. Irregular contractions.
- D. Client reports feeling the urge to push.
Correct Answer: B
Rationale: The transition phase is marked by cervical dilation of 8–10 cm, intense contractions, and significant discomfort.
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Which factor should alert the nurse for the potential of a prolapsed umbilical cord?
- A. Presenting part at station minus 3 (too much empty space in between)
- B. Meconium stained amniotic fluid
- C. Pregnancy at 38 weeks' gestation
- D. Oligohydramnios
Correct Answer: A
Rationale: A presenting part at station minus 3 indicates that there is too much empty space between the presenting part (usually the fetus's head) and the pelvic inlet. This increased space raises the potential for the umbilical cord to prolapse through the cervix and into the birth canal ahead of the baby, especially when the membranes rupture. A prolapsed umbilical cord is a severe obstetric emergency that can cause fetal compromise due to umbilical cord compression and compromise of blood flow. It requires immediate intervention to relieve the pressure on the cord and increase the likelihood of a safe delivery. Therefore, a presenting part at station minus 3 should alert the nurse to the potential of a prolapsed umbilical cord.
During the assessment of a newborn, it is most important for the nurse to report a:
- A. Temperature of 97.7 degrees Fahrenheit
- B. Pale pink, rust-colored stain in the diaper
- C. Heart rate that drops to 120 beats/min
- D. Breathing pattern that is diaphragmatic with sternal retractions
Correct Answer: D
Rationale: Sternal retractions indicate respiratory difficulty.
The best indication that correct attachment to the breast has occurred is when the:
- A. Baby's tongue is securely on top of the nipple.
- B. Baby's mouth covers most of the areolar surface
- C. Baby makes frequent loud clucking sounds while nursing at each breast d, Baby sucks each breast vigorously for five minutes before falling asleep
Correct Answer: B
Rationale: The best indication that correct attachment to the breast has occurred is when the baby's mouth covers most of the areolar surface. This is important because proper latch and attachment are crucial for effective breastfeeding. When the baby's mouth covers most of the areola, it ensures that the baby is latched onto the breast properly, allowing them to feed efficiently and receive an adequate amount of milk. This also helps prevent nipple soreness and pain for the mother. Additionally, when the baby's mouth covers most of the areola, it helps ensure that the baby is positioned correctly to effectively stimulate milk production and flow.
A nurse is caring for a newborn who is 24 hr. old. Which of the following Laboratory findings should the nurse report to the provider?
- A. Hgb 20 g/dL
- B. Bilirubin 2mg/dL
- C. Platelets 200 .000/mm3
- D. WBC count 32.000/mm3
Correct Answer: D
Rationale: A WBC count of 32,000/mm3 is significantly elevated and falls outside the normal range for a newborn. This could indicate an infection or other underlying health issue that requires further investigation and intervention. It is crucial for the nurse to report this abnormal finding to the healthcare provider promptly for appropriate evaluation and management. High WBC counts in newborns are often a cause for concern and may require immediate medical attention.
For which condition should the nurse immediately
- A. Applying her peri-pad from back to front with notify the health care team?
- B. Periodic breathing in the newborn lasting
- C. Using the peri-bottle to rinse her perineum after approximately 3 to 5 seconds
- D. Blood sugar recording of 60 mg/dL in an infant born 6 hours ago
Correct Answer: D
Rationale: A blood sugar recording of 60 mg/dL in an infant born 6 hours ago requires immediate notification of the health care team. This low blood sugar level, also known as hypoglycemia, is a critical concern in newborns as it can lead to serious complications if not promptly addressed. Infants are particularly vulnerable to hypoglycemia due to their limited glycogen stores and high metabolic demands, which can result in inadequate glucose production. Immediate intervention and close monitoring by the healthcare team are essential to prevent potential long-term neurological consequences associated with hypoglycemia in newborns.