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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.
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While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
Preterm labour is defined as spontaneous onset of painful regular uterine contractions at any time prior to:
- A. A stage of fetal viability.
- B. The second stage of labour.
- C. The 32nd week of gestation.
- D. The 37th week of gestation.
- E. The 40th week of gestation.
Correct Answer: D
Rationale: Preterm labor is defined as regular contractions before 37 weeks gestation leading to cervical change. This is the standard cutoff for preterm delivery.
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.
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.
The mother of a healthy 15-hour-old term newborn asks the nurse if the PKU blood test could be completed now on her infant because she and her infant are being discharged to home. Which statement should be the basis for the nurse’s response?
- A. The PKU test must be completed when the infant is at least 1 month of age.
- B. The parents must be required to obtain the test within the first week after discharge if completed before 24 hours of age.
- C. The PKU test is best if completed after the infant is 24 hours old but before 7 days of age.
- D. The PKU test is not needed if the infant is tolerating feedings without diarrhea or vomiting.
Correct Answer: C
Rationale: The PKU test is most accurate after 24 hours and before 7 days allowing sufficient protein intake. Early discharge requires follow-up testing and feeding tolerance doesn’t exempt testing.