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Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn.
- A. Educate the parents to begin range of motion exercises on the affected arm after 1 week.
- B. Assess for grasp reflex in the affected extremity.
- C. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt.
- D. Instruct parents to limit physical handling for 2 weeks.
Correct Answer:
Rationale: Correct Answer: B: Assess for grasp reflex in the affected extremity.
Rationale:
- Assessing for grasp reflex is indicated to evaluate neurologic function and muscle tone in the affected arm.
- This helps in determining the extent of impairment and guiding further interventions.
- Range of motion exercises (A) may worsen the condition if performed too early.
- Immobilizing the arm (C) may lead to joint stiffness and muscle atrophy.
- Limiting physical handling (D) may hinder bonding and infant's development.
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A nurse is reviewing laboratory findings for a client who is at 20 weeks of gestation. Which of the following findings should the nurse report to the provider?
- A. Hematocrit 37% (37% to 47%)
- B. Creatinine 0.9 mg/dL (0.5 to 1 mg/dL)
- C. WBC count 11,000/mm3 (5,000 to 10,000/mm3)
- D. Fasting blood glucose 180 mg/dL (74 to 106 mg/dL)
Correct Answer: D
Rationale: The correct answer is D: Fasting blood glucose 180 mg/dL (74 to 106 mg/dL). A high fasting blood glucose level during pregnancy may indicate gestational diabetes, which can lead to complications for both the mother and the fetus. The nurse should report this finding to the provider for further evaluation and management to prevent adverse outcomes.
Choice A: Hematocrit of 37% falls within the normal range for a pregnant woman and does not require immediate reporting.
Choice B: Creatinine level of 0.9 mg/dL is within the normal range and does not indicate any immediate concerns.
Choice C: WBC count of 11,000/mm3 is slightly elevated but can be a normal response to pregnancy and does not typically require immediate action.
In summary, the correct answer is D because it indicates a potentially serious condition that requires further investigation, while choices A, B, and C are within normal limits for pregnancy and do not raise immediate concerns.
A nurse is teaching about car seat safety to the parents of a newborn who was delivered at 38 weeks of gestation. Which of the following statements by a parent indicates an understanding of the teaching?
- A. I can use a sleep sack to keep my baby warm in the car seat.'
- B. My baby will need a car seat challenge test before discharge.'
- C. The car seat should be positioned in the car at a 45-degree angle.'
- D. When my baby is 1 year old, I can turn their car seat facing forward.'
Correct Answer: C
Rationale: The correct answer is C because positioning the car seat at a 45-degree angle is important for newborns to prevent their head from falling forward and potentially obstructing their airway. This angle helps keep the baby safe and secure during the ride.
Choice A is incorrect because using a sleep sack in the car seat can interfere with the harness straps and compromise the baby's safety.
Choice B is incorrect as a car seat challenge test is conducted for preterm infants, not infants born at 38 weeks of gestation.
Choice D is incorrect because it is recommended to keep infants in a rear-facing position until they reach the height or weight limit specified by the car seat manufacturer, typically around 2 years old.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. When a newborn is born with a nuchal cord (umbilical cord wrapped around the neck), compression can occur, leading to facial petechiae. This occurs due to the increased pressure on the blood vessels in the face during delivery. Telangiectatic nevi (A) are unrelated to nuchal cord. Periauricular papillomas (C) are benign skin lesions often found in newborns but are not specific to nuchal cord. Erythema toxicum (D) is a common benign rash in newborns, but it is not directly associated with a nuchal cord.
A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?
- A. To allow manifestations of infection to be identified
- B. The newborn weighs less than 2.5 kg (5.5 lb)
- C. The newborn was delivered via cesarean birth
- D. To facilitate bonding between the newborn and parent
Correct Answer: D
Rationale: Rationale: The correct answer is D - To facilitate bonding between the newborn and parent. Instillation of antibiotic ointment can interfere with the bonding process between the newborn and parent, as it may create a barrier between them. Bonding is crucial for establishing a strong emotional connection and attachment between the newborn and parent, which is important for the newborn's overall well-being. Delaying the instillation allows for uninterrupted skin-to-skin contact and bonding. Choices A, B, and C are incorrect because delaying antibiotic ointment instillation does not affect the identification of infection manifestations, the newborn's weight, or the mode of delivery.
A nurse is caring for a client who is at 36 weeks of gestation and has methicillin-resistant Staphylococcus aureus. Which of the following types of isolation precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Protective environment
- D. Airborne
Correct Answer: B
Rationale: The correct answer is B: Contact precautions. Methicillin-resistant Staphylococcus aureus (MRSA) is typically spread through direct contact with contaminated skin or surfaces. Therefore, the nurse should initiate contact precautions to prevent the spread of infection. This includes wearing gloves and a gown when providing care to the client, as well as ensuring proper hand hygiene.
Choice A (Droplet precautions) is incorrect because MRSA is not transmitted through droplets in the air. Choice C (Protective environment) is incorrect as this type of isolation is used for clients who are immunocompromised to protect them from environmental pathogens. Choice D (Airborne precautions) is incorrect as MRSA is not transmitted through the airborne route.