Nokea
Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.)
- A. Thin, transparent skin
- B. Vernix only in the body creases
- C. Folded ear springs back slowly
- D. Breast tissue under the nipple
- E. Creases over entire sole
Correct Answer: A,C
Rationale: The only signs of preterm are the thin skin and the slowly responding ear.
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After delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention?
- A. Notify the physician.
- B. Massage the fundus.
- C. Initiate measures that encourage voiding.
- D. Position the patient flat.
Correct Answer: B
Rationale: A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
What should the nurse implement for security purposes when bringing the infant from the nursery to the mother?
- A. Ask, 'Is this your band number?'
- B. Confirm room number of mother.
- C. Ask the mother to identify herself verbally.
- D. Check the band number of the infant with that of the mother.
Correct Answer: D
Rationale: The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
The nurse is assessing a newborn. Which sign would indicate hypoglycemia?
- A. Increased nasal mucus
- B. Increased temperature
- C. Active muscle movements
- D. High-pitched cry
Correct Answer: D
Rationale: There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
In what situation will the physician order RhoGAM?
- A. An unsensitized Rh-negative mother has an Rh-positive infant.
- B. An Rh-negative mother becomes sensitized.
- C. A sensitized infant has a rising bilirubin level.
- D. An unsensitized infant exhibits no outward signs.
Correct Answer: A
Rationale: The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.
What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected?
- A. Teach the patient how to massage the abdomen and then get help.
- B. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
- C. Begin massaging the fundus while another person notifies the physician.
Correct Answer: C
Rationale: Massaging the fundus is the immediate action to stimulate uterine contractions and control bleeding, while another person notifies the physician for further management.