Nokea
What is the most important teaching for a mother of a preterm infant in an incubator?
- A. Emphasize the importance of frequent temperature checks
- B. Demonstrate proper hand hygiene practices
- C. Educate the mother on kangaroo care
- D. Explain the importance of reduced stimulation
Correct Answer: C
Rationale: Educating about kangaroo care promotes bonding and stabilizes the infant's vital signs.
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A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: A
Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.
A woman has been having contractions since 4am this morning. At 8am her cervix dilated 5cm. Contractions are frequent, mild to moderate in intensity. CPD has been ruled out. After giving her sedation so she can rest, what would anticipate preparing her for?
- A. oxytocin induction
- B. Amnioinfusion
- C. c/s
- D. increased IV infusion
Correct Answer: C
Rationale: The scenario describes a woman in active labor with frequent, mild to moderate contractions and significant cervical dilation. If cephalopelvic disproportion (CPD) has been ruled out and the progress of labor is slow despite sufficient dilation and descent of the fetus, it may indicate cephalopelvic disproportion, failure to progress, or other complications that could necessitate a cesarean section (c/s). In this case, providing sedation to allow for rest suggests that the medical team is considering the possibility of further intervention, such as a c/s, if the labor does not progress effectively despite sufficient dilation. Therefore, preparing the woman for a c/s would be the anticipated next step in her care.
What is the initial action for a mother experiencing severe vaginal bleeding during labor?
- A. Monitor vital signs and provide IV fluids
- B. Position the mother on her left side
- C. Administer oxygen at 10L/min via mask
- D. Prepare for an immediate cesarean section
Correct Answer: C
Rationale: Administering oxygen improves maternal and fetal oxygenation during significant bleeding.
The newborn's mother is concerned about the shape of the baby's head after delivery. She states that the baby looks like a "cone head." What is the most appropriate response by the nurse?
- A. "You don't need to worry about it. It is perfectly normal after birth."
- B. "It is molding caused by the pressure during birth and will disappear in a few days."
- C. "I will report it to the physician and recommend a diagnostic scan."
- D. "It is a collection of blood related to the trauma of delivery and will absorb in a few weeks.
Correct Answer: B
Rationale: "It is molding caused by the pressure during birth and will disappear in a few days."
What two steps of the CJMM are included in the assessment step of the nursing process?
- A. noticing cues and evaluating outcomes
- B. analyzing cues and generating solutions
- C. noticing and analyzing cues
- D. analyzing cues and taking action
Correct Answer: A
Rationale: In the assessment step of the nursing process, two steps of the CJMM (Clinical Judgment Model) that are included are noticing cues and evaluating outcomes. Noticing cues involves observing and recognizing relevant information or data related to the patient's health status, while evaluating outcomes involves assessing the effectiveness of the nursing interventions and patient responses to the care provided. By noticing cues, nurses gather information that guides their decision-making process, and by evaluating outcomes, they determine the impact of their actions on the patient's health and adjust the plan of care as needed. These two steps are essential in the assessment phase as they contribute to developing a comprehensive understanding of the patient's needs and progress towards achieving desired health outcomes.