Nokea
What is the priority nursing intervention for a newborn with respiratory distress?
- A. Administer oxygen and position the newborn
- B. Suction the airway and provide stimulation
- C. Start IV antibiotics immediately
- D. Monitor heart rate and blood pressure
Correct Answer: A
Rationale: Administering oxygen and positioning the newborn can improve respiratory function.
You may also like to solve these questions
A male infant delivered at 28 weeks gestation weighs 2 pounds, 12 ounces. When performing an assessment, the nurse would probably observe:
- A. Wide, staring eye
- B. Transparent, red skin
- C. An absence of lanugo
- D. A scrotum with descended testicles
Correct Answer: B
Rationale: A male infant delivered at 28 weeks gestation, as described, would likely have very underdeveloped skin due to the premature birth. The premature skin is often transparent, allowing the prominent blood vessels underneath to be visible, and may also have a reddish hue due to the skin's immaturity. This characteristic appearance is a common finding in premature infants and is a result of their skin being thinner and more fragile than that of full-term infants. The other options, such as a wide, staring eye, an absence of lanugo, and a scrotum with descended testicles, are not specifically associated with premature birth and are not likely to be observed in this scenario.
The nurse is preparing a client for a biophysical profile (BPP). What does this test assess?
- A. Fetal genetic disorders.
- B. Amniotic fluid index and fetal well-being.
- C. Maternal blood flow.
- D. Cervical length.
Correct Answer: B
Rationale: A biophysical profile evaluates fetal well-being by assessing movements, tone, breathing, and amniotic fluid volume.
The nurse is assessing a client in labor with variable decelerations on the fetal monitor. What is the priority intervention?
- A. Increase oxytocin infusion.
- B. Reposition the client.
- C. Administer oxygen at 10 L/min.
- D. Notify the healthcare provider.
Correct Answer: B
Rationale: Repositioning the client can alleviate umbilical cord compression, the most common cause of variable decelerations.
A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client's abdomen, at which of the following positions should the nurse expect to find the uterine fundus?
- A. At the level of the umbilicus
- B. 2 cm above the umbilicus
- C. One fingerbreadth above the symphysis pubis
- D. To the right of the umbilicus
Correct Answer: C
Rationale: After a vaginal delivery, the uterus typically undergoes involution, which is the process of the uterus returning to its pre-pregnancy size and position. At 12 hours postpartum, the uterine fundus should be palpated approximately one fingerbreadth above the symphysis pubis. This position indicates proper contraction of the uterus and helps prevent postpartum hemorrhage. As time progresses, the uterine fundus will gradually descend back into the pelvis.
A client is experiencing uterine atony after delivery. What is the nurse's first action?
- A. Massage the fundus until firm.
- B. Increase IV fluid rate.
- C. Notify the healthcare provider.
- D. Administer prescribed oxytocin.
Correct Answer: A
Rationale: Fundal massage stimulates uterine contraction and is the initial response to uterine atony to prevent hemorrhage.