Nokea
Which of the following findings should the nurse identify as manifestations of the newborn's suspected condition?
- A. Mother's report of feedings.
- B. Oral mucosa findings.
- C. Respiratory findings.
- D. Temperature change.
Correct Answer: B,C
Rationale: Oral mucosa changes (B), such as pallor or cyanosis, may occur due to hypoxia or circulatory compromise. Respiratory changes (C), including tachypnea or retractions, are significant manifestations of stress or pulmonary involvement in neonatal conditions like asphyxia.
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A nurse is assessing a newborn who is 48 hr old and is experiencing opioid withdrawals. Which of the following findings should the nurse expect?
- A. Hypotonicity.
- B. Moderate tremors of the extremities.
- C. Axillary temperature 36.1°C (96.9° F).
- D. Excessive sleeping.
Correct Answer: B
Rationale: Moderate tremors result from central nervous system irritability during withdrawal. Elevated norepinephrine levels lead to excessive stimulation, causing tremors and jitteriness.
A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat at a 90-degree angle.
- D. Place the shoulder harness straps in the slots an inch above your baby's shoulders.
Correct Answer: A
Rationale: Rear-facing car seats support a baby's head and spine during sudden stops or collisions. Experts recommend maintaining this position until 2 years to reduce injury risk.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical manifestations is an adverse effect of epidural anesthesia?
- A. Polyuria.
- B. Hypertension.
- C. Pruritus.
- D. Dry mouth.
Correct Answer: C
Rationale: Pruritus is a frequent side effect of epidural anesthesia, particularly when using opioids like fentanyl, due to histamine release or opioid receptors activation in the spinal cord.
A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct Answer: D
Rationale: The abdomen is the preferred site for subcutaneous heparin injections due to its fatty tissue, which minimizes risks of intramuscular bleeding and ensures consistent drug absorption.
A nurse in the labor and delivery triage unit assesses a client who has been pushing for 2.5 hours with minimal progress. The fetal head remains at +2 station. Which of the following is the most appropriate next action?
- A. Perform a vaginal exam to reassess effacement and dilation.
- B. Notify the primary health care provider about minimal progress.
- C. Prepare the client for vacuum-assisted delivery.
- D. Administer intravenous oxytocin.
Correct Answer: B
Rationale: Notifying the primary health care provider about minimal progress is the most appropriate next action. The client has been pushing for 2.5 hours with minimal progress, which raises concern for potential complications such as cephalopelvic disproportion or maternal exhaustion.