Nokea
The nursery charge nurse is assessing a 1-day-old female on morning rounds. Which of the following findings should be reported to the neonatologist as soon as possible? Select all that apply.
- A. Blood in the diaper.
- B. Grunting during expiration.
- C. Deep red coloring on one side of the body with pale pink on the other side.
- D. Lacy and mottled appearance over the entire chest and abdomen.
Correct Answer: B
Rationale: Grunting indicates respiratory distress, and harlequin coloring suggests vascular compromise.
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A nurse is assessing a 1-day postpartum client who had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg po, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client?
- A. She should be assessed by her doctor.
- B. She should have a sitz bath.
- C. She may have a hidden laceration.
- D. She needs a narcotic analgesic.
Correct Answer: C
Rationale: Hidden lacerations can cause severe pain.
Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage?
- A. Alteration is comfort related to afterbirth pains.
- B. Risk for altered parenting related to grand multiparity.
- C. Fluid volume deficit related to blood loss.
- D. Risk for sleep deprivation related to mothering role.
Correct Answer: C
Rationale: Hemorrhage causes fluid loss.
A mother asks the nurse which powder she should purchase to use on the baby's skin. What should the nurse's response be?
- A. Any powder made especially for babies should be fine.
- B. It is recommended that powder not be put on babies.
- C. There is no real difference except that many babies are allergic to cornstarch so it should not be used.
- D. As long as you put it only on the buttocks area
Correct Answer: B
Rationale: Powder use is discouraged due to inhalation risks.
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like “giving away your child” or “giving up for adoption.”
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient’s expectations for having newborn photos or video.
Correct Answer: D
Rationale: The correct answer is D because asking about the patient's expectations for newborn photos or video shows empathy and support for the mother's emotional needs during this difficult time. It allows the nurse to provide personalized care and helps the mother create lasting memories.
A: Using phrases like "giving away your child" is insensitive and can be hurtful to the mother.
B: Discouraging the mother from holding the baby can be emotionally damaging and is not supportive.
C: Asking why she is giving up her baby can be intrusive and may not be helpful at this moment.
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
- A. Place child in an isolette.
- B. Administer oxygen.
- C. Swaddle baby in a blanket.
- D. Apply pulse oximeter.
Correct Answer: C
Rationale: Cyanosis in extremities is normal in the first few hours due to peripheral vasoconstriction; swaddling provides warmth without unnecessary intervention.