CH.12
How many days should a pt. not get pregnant for following the rubella immunization.
28 days
A 2-year-old sibling of a newborn is displaying behaviors of aggression, regression, and jealousy by hitting the baby on the head. What should the nurse do?
Take them on a tour of the unit, give a gift to a sibling to give to the baby, schedule time for a parent to spend time with them, let them be one of the first to see the newborn, allow older siblings to provide care, provide preschoolers with dolls.
A nurse is caring for a client who has mastitis. What is typical nursing caring for mastitis?
Monitor for pain, inspect breasts, check fundal height, position, and consistency.
A nurse is assessing a newborn for signs of hypoglycemia. Which of the following findings should the nurse identify as a possible indication of hypoglycemia?
a) Jitteriness and tremors
b) Normal respiratory rate of 40 breaths per minute
c) Axillary temperature of 37.2°C (99°F)
d) Soft, pink skin with a brisk capillary refill
a) Jitteriness and tremors
A nurse is caring for a preterm newborn who is receiving gavage feedings due to an immature suck-swallow reflex. Which of the following actions should the nurse take?
a) Feed the newborn only once every 6 hours
b) Lay the newborn flat during the feeding
c) Use a large-gauge feeding tube to speed up the process
d) Offer a pacifier during feedings to promote sucking reflex
d) Offer a pacifier during feedings to promote sucking reflex
Following vaginal delivery, the following visit should take place in how many weeks?
4 to 6 weeks
A newborn chest presents as barrel-shaped, breathing diaphragmatic, with abdomen dome-shaped. Respirations are 60/min and have apnea periods lasting 15 seconds. Baby weight noted in the 85th percentile. What should the nurse do?
Document and move on to the next assessment. Respirations 30-60/ min. Apnea less than 20 seconds is an expected finding. Baby weight is normal, is more than the 90th percentile or less than the 10th percentile.
A nurse is caring for a client who is experiencing postpartum hemorrhage and is currently on Methylergonovine. What should the nurse inform the client about the medication?
ADR: hypertension, nausea, vomiting and headache. DO NOT administer to clients who have hypertension or cardiovascular disease.
A newborn is undergoing a metabolic screening test. Which of the following instructions should the nurse provide to the parents regarding the procedure?
a) "This test should be performed within the first 12 hours of life."
b) "Your baby should not eat for at least 12 hours before the test."
c) "If discharged before 24 hours, the test should be repeated within 1 to 2 weeks."
d) "Heel stick blood collection is not needed for this test."
c) "If discharged before 24 hours, the test should be repeated within 1 to 2 weeks."
A newborn is diagnosed with fetal alcohol syndrome (FAS). Which of the following physical characteristics should the nurse expect?
a) Small palpebral fissures
b) Large head circumference
c) Excessive subcutaneous fat
d) Thick upper lip
a) Small palpebral fissures
One pad saturated in 15 min or less, or pooling under the buttocks is an indication of?
postpartum hemorrhage and should be reported immediately.
Describe the Moro reflex, the tonic neck reflex, Babinski, and the plantar grasp, and the Palmar grasp.
Palmar- put fingers in palm and baby fingers curl around. Moro reflex- put the baby in a semi sitting position and allow it to fall at least 30 degrees, they should extend arms. Tonic neck reflex (Fencing position)- Baby head turns one side and that arm extends out while the opposite side flexes. Plantar grasp- place finger at base of toes and then should curl downward. Babinski reflex- trace bottom of foot starting from the heel and going up crossing the base of toes, toes should fan outward.
A nurse is caring for a client who is postpartum. The patient is experiencing prolonged lochial discharge, increased vaginal bleeding, tachycardia and hypotension. The Nurse should identify that the patient is experiencing which postpartum complication?
Uterine atony
A nurse is reinforcing discharge teaching with new parents about newborn care. Which of the following statements by the parents indicates a need for further teaching?
a) "We will keep the umbilical cord dry and allow it to fall off on its own."
b) "We should avoid using premoistened towelettes to clean the circumcision site."
c) "We will place our newborn on their stomach to sleep to prevent choking."
d) "We should monitor for any signs of infection at the umbilical stump."
c) "We will place our newborn on their stomach to sleep to prevent choking."
A nurse is caring for a preterm newborn who is receiving gavage feedings due to an immature suck-swallow reflex. Which of the following actions should the nurse take?
a) Feed the newborn only once every 6 hours
b) Lay the newborn flat during the feeding
c) Use a large-gauge feeding tube to speed up the process
d) Offer a pacifier during feedings to promote sucking reflex
d) Offer a pacifier during feedings to promote sucking reflex
What are the secretions of clear yellow fluid from the breast called?
Colostrum
A baby axillary temperature is evaluated and is 96.8 F. Grunting and nasal flare noted, with bluish color found around the mouth, mucus noted in the airway. What should the nurse do?
Axillary temperature taken rather than rectal because it can injure delicate rectal membranes. Temperature is too low with the average temperature being 98.6 F with a range of 97.7-99.5 F. The nurse should put the baby in a radiant warmer or warm incubator until temperature stabilizes (check every hour). Respiratory distress also indicated, mucus should be cleared in mouth first then nose with bulb syringe.
A postpartum woman with a history of preeclampsia develops sudden chest pain, shortness of breath, and tachypnea. The nurse notes the presence of crackles in the lungs upon auscultation. What is the most likely cause of the woman’s symptoms?
A. Pulmonary embolism
B. Postpartum hemorrhage
C. Pulmonary edema
D. Fat embolism syndrome
Answer: C. Pulmonary edema
*Rationale: Pulmonary edema is a common complication in women with a history of preeclampsia, especially if they developed severe hypertension. It results from fluid overload and can cause symptoms such as chest pain, shortness of breath, tachypnea,
Which of the following newborn findings requires immediate intervention by the nurse?
a) Skin-to-skin contact with the mother shortly after birth
b) A yellowish mucus film forming over the circumcision site on day two
c) Oxygen saturation of 92% in the right hand and 89% in the right foot
d) A weight loss of 5% from birth weight on day two of life
c) Oxygen saturation of 92% in the right hand and 89% in the right foot
Which of the following findings should the nurse report immediately for a newborn receiving phototherapy for hyperbilirubinemia?
a) Conjunctivitis
b) Skin discoloration with a bronze hue
c) Maculopapular rash
d) Sunken fontanels
d) Sunken fontanels
How would you document the position and location of the uterus that is 1 finger breath above the uterus.
+1
U+1
1/U
A just born, crying female baby appearance is noted as purplish skin with a bluish tint noted on hands and feet with cracks. Genitalia edematous with blood tinged discharge noted. Bulging frontal also noted. What does this indicate?
Document and do nothing. Purple/ deep red skin expected initially. Blue hands and feet and cracks were also expected at first. Gentila findings are also expected. Bulging frontal when quiet indicates increased intracranial pressure, infection, hemorrhage. A depressed one indicates dehydration.
A pregnant woman in active labor has been experiencing prolonged decelerations with the fetal heart rate dropping to 90 bpm during contractions. The nurse administers oxygen via face mask and changes the mother’s position, but the decelerations continue. What should the nurse’s next step be?
A. Prepare for an emergency cesarean section.
B. Increase the intravenous infusion rate of the fluids.
C. Perform a vaginal exam to assess for cord prolapse.
D. Increase the rate of oxytocin to stimulate labor.
Answer: C. Perform a vaginal exam to assess for cord prolapse
A nurse is reinforcing teaching about safe bottle-feeding techniques with a group of new parents. Which of the following statements by a parent indicates an understanding of the teaching?
a) "I will feed my baby in a supine position to prevent choking."
b) "I should microwave the formula for even heating."
c) "I should discard any leftover formula after a feeding."
d) "I will prop the bottle up for my baby to drink at their own pace."
c) "I should discard any leftover formula after a feeding."
A nurse is assessing a newborn with neonatal opioid withdrawal syndrome (NOWS). Which of the following findings should the nurse expect?
a) Prolonged periods of sleep
b) Decreased Moro reflex
c) Hypotonic muscle tone
d) Continuous high-pitched cry
d) Continuous high-pitched cry