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Which action is most important for the nurse to implement?
- A. Increase IV infusion rate.
- B. Assess the vital signs.
- C. Massage the fundus.
- D. Notify the healthcare provider.
Correct Answer: C
Rationale: Massaging the fundus promotes uterine contraction, critical for controlling postpartum hemorrhage and stabilizing the patient.
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A 26-week gestational primigravida who is carrying twins is seen in the clinic today. Her fundal height is measured at 29 cm. Based on these findings, which action should the nurse implement?
- A. Document the finding in the medical record.
- B. Schedule the client for a biophysical profile.
- C. Request another nurse measure the fundus.
- D. Notify the healthcare provider of the finding.
Correct Answer: B
Rationale: A fundal height of 29 cm at 26 weeks in a twin pregnancy is discrepant and may indicate issues like growth restriction or polyhydramnios, necessitating a biophysical profile to assess fetal well-being.
The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding why the nurse is administering this medication?
- A. Improve insufficient dietary intake.
- B. Stimulate the immune system.
- C. Prevent hemorrhagic disorders.
- D. Help an immature liver.
Correct Answer: C
Rationale: Phytonadione (vitamin K) prevents hemorrhagic disorders in newborns by supporting clotting factor synthesis, addressing low vitamin K levels at birth.
A client who is positive for Neisseria gonorrhoeae vaginally delivered a newborn. Which medication should the nurse administer to the newborn?
- A. Erythromycin ointment.
- B. Neomycin ointment.
- C. Tetracaine eye drops.
- D. Latanoprost eye drops.
Correct Answer: A
Rationale: Erythromycin ointment prevents ophthalmia neonatorum from Neisseria gonorrhoeae, protecting the newborn's eyes from infection.
The nurse is reviewing the prescriptions to determine priorities. Which prescriptions take priority?
- A. Bolus of 2 ml/kg glucose 10% IV.
- B. Feed immediately.
- C. Echocardiogram.
- D. Monitor for respiratory distress.
- E. Apply dextrose gel inside the baby's cheek.
Correct Answer: E
Rationale: Applying dextrose gel is a rapid, non-invasive way to treat hypoglycemia, prioritizing immediate glucose stabilization in a jittery newborn.
A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?
- A. Encourage breastfeeding every 2 to 3 hours.
- B. Give zidovudine 6 to 12 hours after birth.
- C. Administer antibiotics for 7 to 10 days.
- D. Delay the initial bath for 1 to 2 days.
Correct Answer: B
Rationale: Zidovudine within 6-12 hours reduces HIV transmission risk in newborns of HIV-positive mothers, unlike breastfeeding, which is contraindicated, or antibiotics and delayed bathing, which are irrelevant.