Nokea
What is the recommended method of feeding for a newborn with phenylketonuria (PKU)?
- A. Breastfeeding
- B. Formula feeding
- C. Lowphenylalanine formula feeding
- D. All of the above
Correct Answer: C
Rationale: Lowphenylalanine formula feeding is recommended for newborns with PKU.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing. 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Place newborn skin to skin on birthing parents chest, Encourage birthing parents to breastfeed, Obtain prescription for arterial blood gases, Plan to initiate phototherapy, Perform neonatal abstinence system scoring
- B. Cold stress, Acute bilirubin encephalopathy, Respiratory distress syndrome, Neonatal abstinence syndrome (NAS)
- C. Stool output, Temperature, Lung sounds, Blood glucose level, Bilirubin level
Correct Answer:
Rationale:
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn can indicate respiratory distress, which is a critical finding that requires immediate attention from the provider to prevent complications. Acrocyanosis (B) is a common finding in newborns and usually resolves on its own. Overlapping suture lines (C) can be normal in newborns due to the molding process during birth. The head circumference of 33 cm (13 in) (D) is within the normal range for a newborn.
A nurse is caring for a client who is in labor and receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?
- A. Contractions every 5 min that last 30 seconds
- B. Montevideo units consistently 300 mm Hg
- C. Urine output of 20 mL/hr
- D. FHR pattern with absent variability
Correct Answer: A
Rationale: Contractions every 5 minutes lasting 30 seconds are inadequate for labor progression, indicating the need to increase oxytocin infusion to strengthen contractions.
A nurse is admitting a client to the birthing unit who reports her contractions started 1 hr ago. The nurse determines the client is 80% effaced and 8 cm dilated. The nurse realizes that the client is at risk for which of the following conditions?
- A. Ectopic pregnancy
- B. Hyperemesis gravidarum
- C. Incompetent cervix
- D. Postpartum hemorrhage
Correct Answer: D
Rationale: The correct answer is D: Postpartum hemorrhage. The nurse assessed the client to be 80% effaced and 8 cm dilated, indicating she is in active labor. This client is at risk for postpartum hemorrhage, which is excessive bleeding after childbirth due to the uterus not contracting adequately to control bleeding. The risk is higher in clients who have a rapid labor progression like this client. Ectopic pregnancy (A) is not relevant in this scenario as the client is already in labor. Hyperemesis gravidarum (B) is severe nausea and vomiting during pregnancy, not related to the client's current condition. Incompetent cervix (C) is the premature dilation of the cervix, not applicable at this stage of labor.
Which of the following is a potential complication of neonatal hypothermia?
- A. Hypoglycemia
- B. Respiratory distress syndrome
- C. Jaundice
- D. All of the above
Correct Answer: D
Rationale: All of the above are potential complications of neonatal hypothermia. Hypothermia can lead to hypoglycemia, respiratory distress, and jaundice due to the infant's inability to regulate body temperature.