Nokea
The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn’s axillary body temperature between 97.7°F (36.5°C) and 98.9°F (37.2°C)? Select all that apply.
- A. Carefully dry the infant immediately after birth.
- B. Place the infant skin-to-skin with the mother.
- C. Apply leggings to both of the newborn’s legs.
- D. Cover the infant’s head with a stocking cap.
- E. Place the infant in a bassinette close to the wall.
Correct Answer: A,B,D
Rationale: Drying the newborn prevents heat loss through evaporation. Skin-to-skin contact with the mother assists in maintaining body temperature. A stocking cap conserves heat. Leggings are unnecessary and placing the bassinette near a wall causes radiation heat loss.
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A G2P1 with previous cesarean section due to obstructed labour comes for first antenatal visit at 34 weeks of gestation. She is seeking advice for home delivery this time. What will be the most dangerous complication in her case if we allow her to deliver at home by untrained birth attendent:
- A. Prolonged latent phase.
- B. Arrest in second stage of labour.
- C. Delayed progress in active phase of labour.
- D. Rupture uterus.
- E. Placental retention.
Correct Answer: D
Rationale: Uterine rupture is a life-threatening complication in women with a previous cesarean section especially during labor managed by untrained attendants due to the risk of scar dehiscence. Other complications are less immediately dangerous.
The physician orders an I.V. opioid analgesic. Which finding by the nurse would best indicate that the I.V. opioid analgesic is effective?
- A. The respiratory rate is within normal limits.
- B. The child's pain level remains stable.
- C. The child is watching television.
- D. The urine output is 30 mL/hour.
Correct Answer: C
Rationale: A child watching television suggests they are comfortable and distracted from pain, indicating effective pain relief from the opioid. Stable pain levels or normal respiratory rate do not directly confirm pain control.
Which statement by the parents indicates they understand the home care instructions given by the nurse?
- A. We've made arrangements for a homebound teacher.
- B. We'll use ice packs on our child's joints during episodes of inflammation.
- C. We'll serve meals that prevent excess weight gain.
- D. We'll keep our child in bed most of the time.
Correct Answer: C
Rationale: Maintaining a healthy weight reduces stress on inflamed joints in JRA. Serving meals that prevent excess weight gain shows understanding of home care instructions to support joint health.
The nurse advises the parents that the child is due to receive which of the following immunization boosters?
- A. Haemophilus influenzae type b (Hib)
- B. Polio
- C. Smallpox
- D. Tetanus
Correct Answer: D
Rationale: A 14-year-old is due for a tetanus-diphtheria-pertussis (Tdap) booster, typically recommended at 11-12 years if not received since age 6, to maintain immunity.
After the delivery of fetus,placenta should be removed by:
- A. Fundal pressure.
- B. D & C.
- C. Brandt-Andrews method.
- D. Manual removal.
- E. C-section.
Correct Answer: C
Rationale: The Brandt-Andrews method using controlled cord traction is the standard technique for delivering the placenta in the third stage of labor. Other methods are used only in complications.