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The nurse is reviewing laboratory results and nurse's notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)
- A. Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.
- B. Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).
- C. Monitor temperature.
- D. Continue to monitor glucose levels.
- E. Explain to the mother that the baby's respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.
- F. Tell the mother that she will need to discuss any concerns with the neonatologist.
- G. Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.
Correct Answer: A,B,C,D
Rationale: Monitoring respiratory distress, temperature, and glucose levels ensures newborn stability, while bilirubin lights treat jaundice, addressing critical neonatal needs.
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A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
The parents of a male newborn have signed an informed consent for circumcision. Which priority intervention should the nurse implement upon completion of the circumcision?
- A. Offer a pacifier dipped in glucose water.
- B. Give a PRN dose of liquid acetaminophen.
- C. Place petrolatum gauze dressings on the site.
- D. Wrap the infant in warm receiving blankets.
Correct Answer: C
Rationale: Petrolatum gauze prevents wound adherence to diapers, reducing irritation and infection risk, prioritizing post-circumcision care.
History and Physical:
Nurses' Notes:
Vital Signs
The neonate was born vaginally at 0130 to a 32-year-old gravida 3, para 3, abortion 0 (G3P3A0) mother. The neonate was born at 39 weeks gestation. The mother had an uncomplicated pregnancy and delivery.
The nurse evaluates the data presented. Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Potential Conditions: Altered respiratory function, Hypoglycemia, Thermoregulation, Sepsis, Hyperbilirubinemia
- B. Actions: Provide manual breaths with a bag-valve mask (BVM), Give dextrose solution orally, Administer intravenous (IV) antibiotics, Place the neonate under a radiant warmer, Perform a heel stick for blood glucose testing
- C. Parameters: Respiratory rate, Temperature, Blood glucose levels, Oxygen saturation, Bilirubin levels
Correct Answer: B,E,C
Rationale: Hypoglycemia is likely due to jitteriness and low temperature; oral dextrose and heel stick glucose testing address it, while monitoring glucose levels and temperature tracks progress.
A primigravida client with gestational hypertension and a Bishop score of 3 is scheduled for induction of labor. The nurse administers misoprostol at 0700, then observes regular contractions with cervical changes at 0900. Which action should the nurse take?
- A. Start oxytocin infusion immediately.
- B. Begin oxytocin 4 hours after misoprostol is given.
- C. Ambulate the client after administration of misoprostol.
- D. Administer misoprostol every 2 hours.
Correct Answer: B
Rationale: Waiting 4 hours before starting oxytocin prevents uterine hyperstimulation, ensuring safer labor induction after misoprostol's cervical ripening effect.
A woman at 36-weeks gestation who is Rh negative is admitted to labor and delivery reporting abdominal cramping. She is placed on strict bedrest and the fetal heart rate and contraction pattern are monitored with an external fetal monitor. Two hours after admission, the nurse notes a large amount of bright red vaginal bleeding. Which nursing intervention has the highest priority?
- A. Confirm Rh and Coombs status for Rho(D) immunoglobulin administration.
- B. Perform sterile vaginal examination to determine dilatation.
- C. Assess the fetal heart rate and client's contraction pattern.
- D. Determine fetal position by performing Leopold maneuvers.
Correct Answer: C
Rationale: Bright red vaginal bleeding suggests possible placental issues; assessing fetal heart rate and contraction pattern is critical to detect fetal distress and guide urgent interventions.