Nokea
When performing daily head to toe assessment of a 1-day old newborn the nurse observes yellow tint to the skin on the forehead, sternum, and abdomen. What action should the nurse take?
- A. Measure bilirubin levels using transcutaneous bilirubinometer
- B. Review maternal medical records for blood type and Rh factor
- C. Prepare the newborn for phototherapy
- D. Evaluate cord results
Correct Answer: A
Rationale: Measuring bilirubin levels (A) is the first step to determine if phototherapy is necessary for jaundice.
You may also like to solve these questions
A 33-year-old client at 9 weeks gestation tells the nurse that while she has 'cut down,' she still has at least one alcoholic drink every evening before bedtime. What intervention should the nurse implement?
- A. Notify child protective services of the client's illicit drug use and probable child endangerment
- B. Praise the client for her actions and offer to discuss ways to decrease consumption even more
- C. Insist that the client stop all alcohol use and draw a blood alcohol level at each prenatal visit
- D. Discuss the risks of alcohol use and encourage complete abstinence
Correct Answer: D
Rationale: Complete abstinence (D) is recommended to prevent fetal alcohol spectrum disorders.
The nurse is caring for a multigravida client in active labor with continuous epidural anesthesia. When the client is 7 cm dilated, her blood pressure drops to 90/50 mm Hg, and the fetal heart rate shows signs of decelerations. What action should the nurse take first?
- A. Place the client in a lateral position.
- B. Administer oxygen via face mask.
- C. Increase the rate of IV fluid infusion.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Placing the client in a lateral position can improve venous return and blood pressure, addressing both maternal hypotension and fetal distress.
A patient in her fifth month of pregnancy asks the nurse, 'How many more calories should I be eating daily?' What is the correct response by the nurse?
- A. 180 more calories a day
- B. 340 more calories a day
- C. 452 more calories a day
- D. 500 more calories a day
Correct Answer: B
Rationale: The correct response is B: 340 more calories a day. During the second trimester, an additional 340 calories per day is recommended for pregnant women. This ensures proper nutrition for both the mother and the developing fetus. Option A (180 more calories) may not provide enough energy for the needs of pregnancy. Options C (452 more calories) and D (500 more calories) are excessive and could lead to unnecessary weight gain, which may pose risks during pregnancy. Option B strikes a balanced approach to support the increased energy demands of pregnancy without being excessive.
The nurse is caring for a laboring client who is GBS+ (Group B streptococcus). Which immediate treatment is indicated for this client?
- A. Administration of Pitocin
- B. Artificial rupture of the membrane
- C. Amnioinfusion for the baby
- D. Administration of antibiotics
Correct Answer: D
Rationale: Antibiotics (D) are administered to GBS+ mothers to prevent neonatal infection.
Regarding advanced roles of nursing, which statement related to clinical practice is the most accurate?
- A. Family nurse practitioners (FNPs) can assist with childbirth care in the hospital setting.
- B. Clinical nurse specialists (CNSs) provide primary care to obstetric patients.
- C. Neonatal nurse practitioners provide emergency care in the postbirth setting to high-risk infants.
- D. A certified nurse midwife (CNM) is not considered to be an advanced practice nurse.
Correct Answer: C
Rationale: Neonatal NPs provide specialized care for high-risk neonates in the birth room and NICU as needed.