Nokea
The nurse makes a home visit to a 3-day-old full-term neonate who weighed 3,912 grams (8 lb, 10 oz) at birth. Today the neonate, who is being bottle-fed, weighs 1,350 grams (7 lb, 14 oz).Which of the following instructions should the nurse give to the mother?
- A. Continue feeding every 3 to 4 hours since the weight loss is normal.
- B. Contact the physician if the weight loss continues over the next few days.
- C. Switch to a soy-based formula because the current one seems inadequate.
- D. Change to a higher-calorie formula to prevent further weight loss.
Correct Answer: A
Rationale: The weight loss from 3,912 g to 3,550 g (7 lb, 14 oz) is approximately 9%, which is within the normal range of up to 10% for newborns in the first few days. Continuing regular feedings is appropriate.
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A nurse is walking down the hall in the main corridor of a hospital. The Code Pink infant security alert system sounds and a Code Pink alert is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?
- A. Move to the entrance of the hospital and check each person leaving.
- B. Go to the obstetrics unit to determine if they need help with the situation.
- C. Call the nursery to ask which baby is missing.
- D. Observe individuals in the area for large bags or oversized coats.
Correct Answer: D
Rationale: Observing for suspicious items like large bags helps identify potential abductors during a Code Pink.
The nurse in the labor and delivery area receives a telephone call from the emergency room announcing that a multigravid client in active labor is being transferred to the labor area. The client has been successful care, when the client arrives by stretcher, she says, 'I think the baby's coming ... Help!' The fetal skull is crowning. The nurse should obtain which of the following information first?
- A. Estimated date of delivery.
- B. Amniotic fluid status.
- C. Gravida and parity.
- D. Prenatal history.
Correct Answer: A
Rationale: With crowning, delivery is imminent, and confirming the estimated date of delivery ensures the neonate's gestational age is known for resuscitation planning. Fluid status, gravida/parity, and prenatal history are secondary.
A full-term neonate is admitted to the normal newborn nursery. The nurse notes a Moro reflex. What should the nurse do next?
- A. Call a code.
- B. Identify this reflex as a normal finding.
- C. Place the neonate on seizure precautions.
- D. Start supplemental oxygen.
Correct Answer: B
Rationale: The Moro reflex is a normal finding in full-term neonates, indicating a healthy neurological response.
A 31-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor is receiving intravenous lactated Ringer's solution and a continuous epidural anesthetic. During the first hour after administration of the anesthetic, the nurse should monitor the client for:
- A. Hypotension.
- B. Diaphoresis.
- C. Headache.
- D. Tremors.
Correct Answer: A
Rationale: Epidural anesthesia can cause sympathetic blockade, leading to hypotension, especially within the first hour. Monitoring blood pressure is critical. Diaphoresis, headache, or tremors are less common or less urgent.
When preparing the room for admission of a multigravid client at 36 weeks' gestation diagnosed with severe preeclampsia, which of the following should the nurse obtain?
- A. Oxytocin infusion solution.
- B. Disposable tongue blades.
- C. Portable ultrasound machine.
- D. Padding for the side rails.
Correct Answer: D
Rationale: Padding for the side rails is necessary to prevent injury during potential seizures.