Nokea
The postpartum client (G2P2) asks the nurse for suggestions to help facilitate her 3-year-old’s attachment and acceptance of their newborn. Which action should the nurse suggest?
- A. Provide a doll for the 3-year-old to care for and nurture.
- B. Avoid bringing the 3-year-old to the “scary” hospital.
- C. Plan that dad cares for the 3-year-old and mom cares for the baby.
- D. Encourage the child to be “grown up” and accept the newborn.
Correct Answer: A
Rationale: Providing a doll encourages the 3-year-old to mimic parental care reducing jealousy. Hospital visits shared parental attention and accepting regression promote bonding.
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The nurse caring for a 32-weeks’ gestation infant is about to perform a heel stick to obtain blood for a prescribed test. Which intervention should the nurse utilize to minimize the amount of pain the neonate will experience?
- A. Apply an ice pack
- B. Apply a heel warmer
- C. Give morphine sulfate
- D. Give sucrose or Sweet-Ease
Correct Answer: D
Rationale: Sucrose activates the endogenous opioid system providing analgesia for 3–5 minutes when given 2 minutes prior to a heel stick. Ice risks skin damage heel warmers aid blood flow and morphine is inappropriate.
A 24 years old G3P2 presents to you at 32 weeks of gestation with preterm prelabour rupture of membranes for ten days. She is complaining of pain in lower abdomen,fever with rigors and chills and purulent vaginal discharge. What is her diagnosis:
- A. Pyrexia of unknown origin.
- B. Puerperal pyrexia.
- C. Preterm labour.
- D. Chorioamnionitis.
- E. Antepartum haemorrhage.
Correct Answer: D
Rationale: Chorioamnionitis is an infection of the amniotic membranes often following prolonged rupture of membranes presenting with fever abdominal pain and purulent discharge. Other options do not fit the clinical picture.
The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice?
- A. Remove the infant’s diaper and look at the color of the genitalia.
- B. Apply pressure on the forehead for 3 seconds,release and evaluate the skin color.
- C. Assess the color of the palms and compare that skin color to the color of the soles.
- D. Open the infant’s mouth to assess the color of the infant’s tongue and palate.
Correct Answer: B
Rationale: To differentiate jaundice from normal skin color apply pressure over a bony area like the forehead. A yellow blanched area indicates jaundice. Genitalia palms soles or oral mucosa are less reliable due to slower progression or darker pigmentation.
Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.
- A. The child complains of being thirsty.
- B. The child's breathing is labored and prolonged.
- C. The child is more hungry than usual.
- D. The child complains of feeling shaky.
- E. The child reports feeling light-headed.
- F. The child states his or her heart is racing.
Correct Answer: D,E,F
Rationale: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.