Nokea
Which of the following would the nurse identify as an abnormal finding?
- A. Red blood cells (RBCs): 4.9million/ul
- B. Hematocrit: 45%
- C. Platelets: 115,000/ul
- D. None of the above
Correct Answer: C
Rationale: The normal range for platelets in adults is typically between 150,000 to 400,000 platelets per microliter of blood. A platelet count of 115,000/ul would be considered low, a condition known as thrombocytopenia. Thrombocytopenia can result in difficulty with blood clotting and may lead to increased risk of bleeding. Therefore, a platelet count of 115,000/ul would be identified as an abnormal finding by the nurse.
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A 40 year old woman with aplastic anemia is prescribed estrogen with progesterone. The nurse can expect that these medications are given for which of the following reasons?
- A. To stimulate bone growth
- B. To enhance sodium and potassium
- C. To regulate fluid balance absorption
- D. To promote utilization and storage of fluids
Correct Answer: A
Rationale: Estrogen plays a crucial role in maintaining bone density and promoting bone growth in both men and women. Aplastic anemia is a condition where the bone marrow does not produce enough blood cells, leading to low blood cell counts. Estrogen therapy is often used in aplastic anemia to help stimulate bone growth and improve bone health. Additionally, estrogen can help protect against bone loss, which is important for overall bone health in individuals with this condition. Progesterone is commonly prescribed along with estrogen to provide a balanced hormonal therapy approach.
A blood sample for measurement of bilirubin is required from a newborn receiving phototherapy. In what environment should this blood sample be drawn?
- A. While phototherapy lights are turned off
- B. While newborn remains under phototherapy lights
- C. When newborn is covered with a blanket
- D. When newborn has been off phototherapy for 30 to 60 minutes
Correct Answer: D
Rationale: The blood sample for measurement of bilirubin should be drawn when the newborn has been off phototherapy for 30 to 60 minutes. The reason for this is that phototherapy can alter bilirubin levels through photoisomerization, making it challenging to interpret the results accurately while the newborn is still under the lights. Allowing a period of 30 to 60 minutes for the newborn to be off phototherapy helps to ensure that the bilirubin level obtained from the blood sample reflects a more accurate baseline level. This practice helps in guiding clinical management decisions related to managing hyperbilirubinemia in newborns.
Which characteristic is representative of the newborn's gastrointestinal tract?
- A. Stomach capacity is approximately 90 ml.
- B. Peristaltic waves are relatively slow.
- C. Overproduction of pancreatic amylase occurs.
- D. Intestines are shorter in relation to body size.
Correct Answer: D
Rationale: The characteristic representative of the newborn's gastrointestinal tract is that the intestines are shorter in relation to the body size. This is because a newborn's gastrointestinal tract is still developing and adapting to the digestion and absorption of nutrients. The proportion of the intestines to the body size is smaller in newborns compared to adults. Over time, as the newborn grows and matures, the intestines will also lengthen and increase in capacity to efficiently process food and absorb nutrients.
A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?
- A. Switch to bottle feeding the baby for 2 weeks
- B. Stop the breast feedings and switch to bottle-feeding permanently
- C. Feed the newborn infant less frequently
- D. Continue to breastfeed every 2-4 hours.
Correct Answer: D
Rationale: The most appropriate instruction for a mother of a newborn infant with hyperbilirubinemia who is being breastfed is to continue to breastfeed every 2-4 hours. Breastfeeding should be initiated within 2 hours after birth and continued every 2-4 hours thereafter. Breast milk helps to promote the passage of meconium (the dark green stools of the newborn) and reduce the risk of hyperbilirubinemia. It is important to continue breastfeeding to establish and maintain a good milk supply, promote bonding between mother and baby, and provide important nutrients to the newborn. Switching to bottle feeding or feeding the newborn infant less frequently is not recommended in this case.
The nurse is caring for a high-risk newborn with an umbilical catheter in a radiant warmer. The nurse notes blanching of the feet. Which is the most appropriate nursing action?
- A. Elevate feet 15 degrees.
- B. Place socks on newborn.
- C. Wrap feet loosely in prewarmed blanket.
- D. Report findings immediately to the practitioner.
Correct Answer: C
Rationale: When the nurse notes blanching of the feet in a high-risk newborn with an umbilical catheter in a radiant warmer, the most appropriate nursing action is to wrap the feet loosely in a prewarmed blanket. Blanching indicates poor circulation to the area, which can be a result of cold stress or constriction of blood vessels. By wrapping the feet in a prewarmed blanket, the nurse can help to restore adequate blood flow to the feet and improve circulation. This action addresses the potential cause of the blanching and promotes the newborn's comfort and well-being.