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The nurse is informed that a newborn infant with Apgar scores of 1 and 4 will be brought to the neonatal intensive care unit (NICU). The nurse determines that which intervention is the priority?
- A. Turning on the apnea#nbsp;apnea and cardiorespiratory monitor.
- B. Connecting the resuscitation bag to oxygen.
- C. Setting up the radiant warmer control temperature at 36.4°C (97.5°F).
- D. Preparing for the insertion of an intravenous (IV) line with D5W.
Correct Answer: B
Rationale: The correct answer is B: Connecting the resuscitation bag to oxygen. This intervention is the priority because the infant has low Apgar scores, indicating poor oxygenation and respiratory effort. Providing oxygen through the resuscitation bag will help improve oxygenation and support the infant's breathing, which is crucial in the immediate postnatal period.
Turning on the apnea and cardiorespiratory monitor (Choice A) may be important for continuous monitoring but addressing the oxygenation issue takes precedence. Setting up the radiant warmer control temperature (Choice C) is important for maintaining the infant's body temperature but not the immediate priority. Preparing for IV insertion with D5W (Choice D) is not necessary at this moment as the priority is to address the respiratory distress.
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A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use
- B. Blunt force trauma
- C. Hypertension
- D. Cigarette smoking
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption because it can lead to reduced blood flow to the placenta, increasing the risk of separation. High blood pressure can cause damage to the blood vessels in the placenta, making it more susceptible to detachment. Cocaine use (A) and cigarette smoking (D) can also increase the risk of abruption, but they are not as common as hypertension. Blunt force trauma (B) can directly cause placental abruption but is not as prevalent as hypertension in this context.
A nurse in a provider’s office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption?
- A. Cocaine use.
- B. Blunt force trauma.
- C. Hypertension.
- D. Cigarette smoking.
Correct Answer: C
Rationale: The correct answer is C: Hypertension. Hypertension is the most common risk factor for placental abruption due to the increased pressure on the placenta, leading to separation from the uterine wall. Cocaine use (A) and cigarette smoking (D) can also increase the risk but are not as common as hypertension. Blunt force trauma (B) can cause a sudden separation of the placenta but is less common compared to hypertension in a routine prenatal setting.
An 8-pound 15-ounce baby born at 35 weeks’ gestation would be described using which terminology? Select all that apply.
- A. Small for gestational age
- B. Term
- C. Preterm
- D. Average for gestational age
- E. Post term
Correct Answer: C,D
Rationale: The correct answer is C and D. Choice C, "Preterm," is correct because a baby born at 35 weeks' gestation is considered preterm, as full term is typically around 39-40 weeks. Choice D, "Average for gestational age," is also correct because the baby's weight falls within the normal range for babies born at 35 weeks. Choice A, "Small for gestational age," is incorrect as the baby's weight is appropriate for its gestational age. Choice B, "Term," is incorrect because 35 weeks is considered preterm. Choice E, "Post term," is incorrect as it refers to a baby born after 42 weeks' gestation.
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother asks, “How will I know if my baby gets enough breast milk?” Which of the following responses should the nurse make?
- A. Your baby should wet 6 to 8 diapers per day.
- B. Your baby should have a wake cycle of 30 to 60 minutes after each feeding.
- C. Your baby should burp after each feeding.
- D. Your baby should sleep at least 6 hours between feedings.
Correct Answer: A
Rationale: The correct answer is A: Your baby should wet 6 to 8 diapers per day. This is because the frequency of wet diapers indicates that the newborn is getting enough breast milk. An adequate amount of wet diapers signifies that the baby is adequately hydrated and receiving sufficient nourishment. It is a concrete and measurable way to monitor the baby's intake.
Choice B is incorrect because the wake cycle after feeding varies among newborns and is not a reliable indicator of milk intake. Choice C is incorrect as burping after feeding is a normal process but not necessarily an indicator of sufficient milk intake. Choice D is incorrect because newborns typically need to feed more frequently than every 6 hours.
A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse anticipate administering? Select all that apply:
- A. Antibiotic ointment to both eyes
- B. Hepatitis B immunization
- C. Lidocaine gel to the umbilical stump
- D. Haemophilus influenzae type b immunization
- E. Vitamin K injection
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A: Antibiotic ointment to both eyes is given to prevent neonatal conjunctivitis. B: Hepatitis B immunization is crucial for newborns to prevent Hepatitis B infection. E: Vitamin K injection is given to prevent hemorrhagic disease of the newborn. C: Lidocaine gel to the umbilical stump is not a standard practice and can cause local irritation. D: Haemophilus influenzae type b immunization is typically given later in infancy, not immediately after birth.