Nokea
Which assessment finding should the nursery nurse report to the pediatric healthcare provider?
- A. Blood glucose level of 45 mg/dl
- B. Blood pressure of 82/45 mmHg
- C. Non-bulging anterior fontanel
- D. Central cyanosis when crying
Correct Answer: D
Rationale: An infant who demonstrates central cyanosis when crying (D) is manifesting poor adaptation to extrauterine life which should be reported to the healthcare provider for determination of a possible underlying cardiovascular problem.
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A multigravida client arrives at the labor and delivery unit and tells the nurse that her bag of water has broken. The nurse identifies the presence of meconium fluid on the perineum and determines the fetal heart rate is between 140 to 150 beats/minute. What action should the nurse implement next?
- A. Complete a sterile vaginal exam
- B. Take maternal temperature every 2 hours
- C. Prepare for an immediate cesarean birth
- D. Obtain sterile suction equipment
Correct Answer: A
Rationale: A vaginal exam (A) should be performed after the rupture of membranes to determine the presence of a prolapsed cord.
The nurse is teaching a client with gestational diabetes about nutrition and insulin need for pregnancy. Which content should the nurse include in this client teaching plan?
- A. Insulin production is decreased during pregnancy
- B. Increase daily caloric intake is needed
- C. Injection requirements remain the same
- D. Blood sugars need less monitoring in the first trimester
Correct Answer: B
Rationale: An increase in caloric intake is often necessary to meet the increased metabolic demands of pregnancy, especially in clients with gestational diabetes.
A pregnant client with mitral stenosis Class III is prescribed complete bedrest. The client asks the nurse, 'Why must I stay in bed all the time?' Which response is best for the nurse to provide this client?
- A. Complete bedrest decreases oxygen needs and demands on the heart muscle tissue.
- B. You have a small opening in your heart and complete bedrest will help it get bigger.
- C. We want your baby to be healthy, and this is the only way we can make sure that will happen.
- D. Labor is difficult, and you need to save your energy so you will be strong enough then.
Correct Answer: A
Rationale: Complete bedrest decreases oxygen needs and demands on the heart muscle tissue, which is crucial for clients with mitral stenosis.
Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mothers vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse implement first?
- A. Have the client empty her bladder
- B. Inspect the perineum for lacerations
- C. Increase oxytocin IV infusion
- D. Perform fundal massage until firm
Correct Answer: D
Rationale: Fundal massage (D) helps control bleeding by stimulating uterine contractions.
A newborn infant is receiving immunization prior discharge. Which action should the nurse implement?
- A. Give the first dose of the vaccine for rotavirus if any have diarrhea now.
- B. Obtain signed consent from the mother for administration of hepatitis B vaccine
- C. Prepare the first dose for DTaP
- D. Ask the mother if she wants the infant immunized for
Correct Answer: B
Rationale: Hepatitis B vaccine is routinely given at birth, and consent is required (B).