Nokea
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter,which actions should be planned by the nurse? Select all that apply.
- A. Check the position marking on the catheter every shift.
- B. Position the tubing close to the infant’s lower limbs.
- C. Check for erythema or discoloration of the abdominal wall.
- D. Palpate for femoral,pedal,and tibial pulses every 2 to 4 hours.
- E. Reposition the catheter tubing every hour.
- F. Monitor blood glucose levels.
Correct Answer: A,C,D,F
Rationale: Check catheter position abdominal wall pulses every 2–4 hours and glucose levels to monitor for displacement bleeding perfusion issues or hypoglycemia. Keep tubing away from limbs and avoid frequent repositioning to reduce infection risk.
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The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn’s HR is 80 bpm. What should the nurse do next?
- A. Assign a 2 for the Apgar score that pertains to the heart rate.
- B. Suction the excess secretions from the newborn’s oral cavity.
- C. Wrap in warm blankets and place on the mother’s abdomen.
- D. Begin immediate positive pressure ventilation on the newborn.
Correct Answer: D
Rationale: A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff® ventilation. A score of 2 requires HR above 100 bpm. Suctioning is not indicated and wrapping is done after assessment.
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.
Which question is most important for the nurse to ask the adolescent girl in preparation for X-rays?
- A. Is there any possibility that you're pregnant?
- B. Have you eaten anything in the past 24 hours?
- C. Have you taken any medications in the past 24 hours?
- D. Are you allergic to iodine or shellfish?
Correct Answer: A
Rationale: Asking about pregnancy is critical before X-rays, as radiation can harm a fetus, making it the most important question to ensure safety.
The most common side effect of tocolytic agents is:
- A. Vaginal bleeding.
- B. Abdominal pain.
- C. Nausea,vomiting.
- D. Palpitations.
- E. Oliguria.
Correct Answer: D
Rationale: Tocolytics such as beta-agonists commonly cause palpitations due to their sympathomimetic effects. Other side effects are less frequent or not primarily associated.
A 30 years old G3P2 at 28 weeks of gestation presents with severe pain in the right flank radiating to her groin. She also complaints of rigors and chills. Urine analysis reveals numerous pus cells. The most likely diagnosis is:
- A. Appendicitis.
- B. Pyelonephritis.
- C. Round ligament torsion.
- D. Meckel's diverticulum.
- E. Torsion of ovarian cyst.
Correct Answer: B
Rationale: Pyelonephritis a urinary tract infection affecting the kidneys presents with flank pain fever,chills,and pus cells in urine,as described. Appendicitis typically involves right lower quadrant pain and other options lack urinary findings or are less likely in pregnancy.