Using the Neonatal Infant Pain Scale (NIPS), a nurse is assessing the pain response of a newborn who has just had a circumcision. The nurse is assessing a change in which of the following signs/symptoms? Select all that apply.
Rationale:
The nurse is assessing a change in heart rate using the Neonatal Infant Pain Scale (NIPS).
Heart rate is a vital physiological indicator included in NIPS to evaluate neonatal pain by detecting autonomic nervous system responses. During painful stimuli like circumcision, heart rate typically increases, reflecting distress. This measure aids in objective pain assessment, ensuring appropriate pain management for the newborn based on observable physiological changes.
B: Blood pressure is not part of the NIPS criteria, which focuses on behavioral and specific physiological signs rather than broader cardiovascular measures.
C: Temperature remains unaffected by acute pain and is excluded from NIPS, as it does not provide immediate evidence of pain response in newborns.
D: Facial expression is a critical component of NIPS, but it was not listed as a correct answer here, highlighting the focus on physiological rather than behavioral indicators in this specific assessment.
A nurse is providing discharge teaching to the parents of a newborn. Which of the following should be included when teaching the parents how to care for the baby's umbilical cord?
Rationale:
Call the doctor if greenish drainage appears.
Greenish drainage from the umbilical cord indicates a possible infection, which requires prompt medical evaluation to prevent complications. Parents should be instructed to monitor for signs of infection such as foul odor, redness, or discharge, and seek healthcare advice immediately if these symptoms occur to ensure the newborn's safety and proper healing of the cord.
A: Cleanse it with hydrogen peroxide if it starts to smell. Hydrogen peroxide can delay healing and damage tissue; gentle cleaning with water is preferred unless otherwise directed by a healthcare provider.
B: Remove it with sterile tweezers at one week of age. The umbilical cord stump naturally separates on its own; manual removal can cause bleeding or infection.
D: Cover it with sterile dressings until it falls off. The cord stump should be exposed to air to dry and heal properly; covering it can trap moisture and promote infection.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time?
Rationale:
The nurse's most appropriate response at this time is, "When did these symptoms begin?"
This question helps determine the onset and duration of symptoms, allowing the nurse to distinguish between transient "baby blues" and more serious postpartum depression or anxiety, guiding appropriate intervention. Timing is crucial to assess severity, progression, and whether immediate referral or further assessment is needed to ensure the patient's safety and mental health.
B: "Sounds like normal postpartum depression." This statement inaccurately labels the symptoms without assessment, potentially minimizing serious conditions and discouraging open communication or timely evaluation.
C: "Are you having trouble getting enough sleep?" This focuses narrowly on sleep issues, neglecting other emotional or psychological factors, and does not initially explore symptom duration or severity.
D: "Are you able to get out of bed and provide care for your baby?" This question assumes functional impairment without first understanding symptom onset or emotional context, potentially overlooking early signs needing assessment.
The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts?
Rationale:
Gently massage the areas toward the nipple, especially during feedings. This advice helps relieve blocked milk ducts by encouraging milk flow and reducing engorgement. Massaging tender, hard nodules promotes drainage, prevents worsening of mastitis, and supports continued breastfeeding. It is a practical, non-invasive intervention that addresses the problem directly, enhancing comfort and preventing complications associated with milk stasis.
B: Apply ice to the areas between feedings reduces swelling but does not facilitate milk flow or resolve blocked ducts, making it less effective for treating tender nodules caused by milk stasis.
C: Bottle feed for the next twenty-four hours interrupts breastfeeding, which can worsen milk stasis and engorgement. It does not address the underlying issue of blocked ducts and may hinder milk removal.
D: Apply lanolin ointment to the areas after each and every breastfeeding treats nipple soreness and cracking but does not alleviate tender, hard nodules or promote milk drainage from blocked ducts.
The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
Rationale:
Respirations are too low, a sign of medication toxicity.
Respirations at 12 per minute are at the lower limit of normal, which could indicate respiratory depression commonly caused by opioid analgesics administered post-cesarean. This low respiratory rate warrants careful monitoring for medication toxicity, as opioids slow respiratory drive, making this interpretation clinically significant in the immediate postoperative period for cesarean clients.
A: Temperature is elevated, a sign of infection. The temperature of 100.0°F is only mildly elevated and can be normal postpartum due to inflammation, not necessarily indicating infection at this stage.
B: Pulse is too low, a sign of vagal pathology. A pulse of 68 bpm is within normal resting range and does not suggest vagal nerve dysfunction or pathology in this clinical context.
D: Blood pressure is elevated, a sign of preeclampsia. Blood pressure of 130/80 mmHg is within normal limits postpartum and does not indicate hypertensive disorders like preeclampsia.
In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
Rationale:
One of the woman's calves is swollen, red, and warm to the touch. This answer indicates classic signs of deep vein thrombosis, including inflammation, redness, swelling, and warmth, which result from a blood clot obstructing venous return. These symptoms warrant urgent reporting to prevent complications like pulmonary embolism. Prompt recognition and intervention are crucial in managing DVT effectively and ensuring patient safety.
A: The woman complains of numbness in the toes and heel of one foot. Numbness suggests nerve involvement or peripheral neuropathy rather than vascular obstruction typical of DVT, which primarily presents with pain, swelling, and erythema.
B: The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. Cramping pain relieved by dorsiflexion characterizes muscle strain or claudication, not DVT, which usually worsens with movement and involves swelling and redness.
D: The veins in the ankle of one of the woman's legs are spider-like and purple. Spider veins indicate superficial venous insufficiency or varicosities, lacking the acute inflammation and pain signs found in deep vein thrombosis scenarios.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
Rationale:
Placing the baby in a fetal position is not an appropriate action when evaluating for developmental dysplasia of the hip (DDH).
D is correct because the fetal position does not facilitate proper assessment of hip stability or movement, which are critical for identifying DDH. Evaluation requires specific maneuvers that allow detection of hip dislocation or subluxation, which cannot be done effectively in this position.
A: Grasping the baby's legs with thumbs on the inner thighs and forefingers on the outer thighs enables controlled movement necessary to perform hip stability tests like Ortolani and Barlow maneuvers.
B: Gently adducting and abducting the thighs is essential to detect abnormal hip movement or clicks, indicating potential dysplasia or dislocation in the hip joint.
C: Palpating the trochanter during hip rotation helps identify any irregularities or asymmetry in hip joint positioning, aiding in detecting DDH signs.
Which of the following full-term babies requires immediate intervention?
Rationale:
Baby with seesaw breathing requires immediate intervention. Seesaw breathing indicates respiratory distress where the chest and abdomen move paradoxically, reflecting inadequate respiratory effort and possible airway obstruction, hypoxia, or increased work of breathing. Immediate action is necessary to prevent deterioration. This sign signals compromised ventilation, demanding prompt assessment and management to stabilize oxygenation and prevent respiratory failure.
B: Baby with irregular breathing and 10-second apnea spells experiences normal neonatal periodic breathing. Short apnea intervals under 20 seconds are typical in full-term infants and usually require monitoring, not urgent intervention.
C: Baby with coordinated thoracic and abdominal breathing demonstrates normal respiratory mechanics, indicating effective ventilation and no immediate cause for concern or emergency treatment.
D: Baby with respiratory rate of 52 falls within the upper normal limit for newborns (30-60 breaths per minute), representing normal physiology without an urgent need for intervention.
To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
Rationale:
Pelvic floor exercises help strengthen muscles involved in urinary control, which supports adequate urinary elimination during the postpartum period.
D: Pelvic floor exercises improve muscle tone and bladder control, reducing urinary retention or incontinence. This directly facilitates proper urinary elimination and addresses common postpartum urinary challenges by enhancing pelvic muscle strength and function.
A: Drinking carbonated beverages does not promote urinary excretion and may cause discomfort or bloating, offering no direct benefit to urinary elimination postpartum.
B: Postpartum diuresis increases fluid loss, but it does not eliminate the risk of dehydration; assuming less risk may neglect necessary hydration care.
C: Limiting fluid intake can lead to concentrated urine and urinary retention, worsening elimination issues instead of preventing polyuria after delivery.
A baby boy is to be circumcised by the mother's obstetrician. Which of the following actions shows that the nurse is being a patient advocate?
Rationale:
The nurse prepares the sterile field for the physician. This action ensures the procedure is conducted under sterile conditions, protecting the baby from infection and demonstrating advocacy by prioritizing patient safety and readiness. It reflects the nurse’s role in facilitating a safe environment, supporting the physician’s work, and safeguarding the infant’s health throughout the circumcision process.
A: Before the procedure lacks specificity about advocacy or patient protection, failing to demonstrate proactive involvement or safeguarding the baby's well-being during circumcision preparation.
C: The nurse refuses to unclothe the baby until the doctor orders something for pain shows resistance without constructive action, neglecting patient advocacy responsibilities by delaying necessary care.
D: The nurse holds the feeding immediately before the circumcision does not directly relate to patient advocacy or safety during the procedure, missing the critical preparation aspect required for protection.
The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis?
Rationale:
Blood loss of 2,000 mL is consistent with placenta accreta due to abnormal adherence of the placenta to the uterine wall, causing difficulty in placental separation and resulting in severe hemorrhage during delivery. This excessive bleeding poses a significant risk and is a common complication requiring prompt management to prevent maternal morbidity or mortality.
B: Blood pressure of 160/110 reflects hypertension, which is unrelated to placenta accreta. This condition primarily involves abnormal placental attachment and bleeding rather than elevated blood pressure.
C: Jaundiced skin color indicates liver dysfunction or hemolysis, not a direct consequence of placenta accreta. The disorder primarily affects placental implantation and bleeding risks.
D: Shortened prothrombin time suggests enhanced blood clotting, whereas placenta accreta is associated with bleeding complications, not accelerated coagulation profiles.
A breastfeeding woman calls the pediatric nurse with the following complaint:"I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I have my husband feed the baby until I get better?"Â Which of the following replies by the nurse is appropriate at this time?
Rationale:
Breastfeeding should continue during maternal illness to protect the baby, so the nurse appropriately advises that the mother keep breastfeeding rather than switching to formula. Breast milk contains antibodies that help protect the infant from infections, and temporary maternal cold does not warrant stopping breastfeeding. Maintaining breastfeeding supports the baby’s immune defense and promotes recovery.
A: Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes. This neglects the benefit of breast milk’s antibodies and suggests unnecessary formula use during mild maternal illness.
B: Don't forget to pump your breasts every 3 hours while the baby is being fed the prescribed formula. Pumping is unnecessary if breastfeeding continues, and this advice implies stopping breastfeeding which is not recommended.
D: In addition to giving the baby formula, you should wear a surgical face mask when you are around him. Mask use is prudent for infection control but does not justify switching to formula from breastfeeding during a cold.
A full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Rationale:
The nurse should assess the Apgar score first. Assessing the Apgar score immediately after birth evaluates the newborn's vital signs and overall condition, guiding urgent interventions if necessary. This quick assessment includes heart rate, respiratory effort, muscle tone, reflex response, and color, providing essential information for prioritizing care and ensuring the infant’s immediate well-being.
A: Remove wet blankets Removing wet blankets is important to prevent heat loss but is secondary to assessing the newborn’s vital signs and overall condition immediately after birth. It follows the initial critical assessment.
C: Insert eye prophylaxis Eye prophylaxis prevents infection but is not the first priority; initial newborn stabilization and assessment must occur before preventive treatments are applied.
D: Elicit the Moro reflex Testing the Moro reflex checks neurological function but is performed after confirming the newborn’s stability and vital signs through initial assessments like the Apgar score.
The nurse does not hear the baby swallow when suckling even though the baby appears to be latched properly to the breast. Which of the following situations may be the reason for this observation?
Rationale:
The baby lies with the chin touching the under part of the breast. This position can block the baby's mouth, restricting effective swallowing despite appearing latched properly. Proper alignment with the chin slightly away from the breast ensures unobstructed swallowing sounds, indicating successful milk transfer during feeding, which explains why no swallowing noise is heard in this scenario.
A: The mother reports a pain level of 4 on a 5-point scale. Pain levels do not directly influence the baby’s swallowing sounds; discomfort primarily affects the mother, not the audible evidence of effective suckling.
B: The baby has been suckling for over 10 minutes. Duration of suckling alone does not affect the presence of swallowing sounds, as swallowing depends on latch quality and position rather than time spent.
C: The mother uses the cross-cradle hold while feeding. The feeding hold choice rarely impacts swallowing audibility; proper latch and positioning are more critical factors than the specific hold employed during breastfeeding.
Research has shown what intervention increases involvement of the adolescent partner postpartum?
Rationale:
Involvement of the partner during the prenatal period increases adolescent partner involvement postpartum. This approach fosters early bonding, enhances partner confidence, and prepares them for active participation after birth. Engaging partners prenatally also helps address concerns and builds supportive behaviors, ensuring they remain connected and involved during the critical postpartum phase, thus improving overall family dynamics and child care outcomes.
B: Involvement of parents in decision making focuses on older family members, not the adolescent partner, thus it does not directly enhance the partner’s postpartum engagement or participation in newborn care.
C: Restricting people in the labor room limits support but does not specifically promote adolescent partner involvement postpartum; it focuses on immediate labor conditions rather than ongoing partner engagement.
D: Providing newborn care in the nursery removes opportunities for partner interaction and caregiving, which may reduce rather than increase adolescent partner involvement during the postpartum period.
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
Rationale:
The nurse would expect to see swelling at the injection site after administering RhoGAM.
Swelling at the injection site is a common localized reaction to RhoGAM, which is an immunoglobulin given to prevent Rh incompatibility. This mild adverse effect results from the body's inflammatory response to the injection, typically resolving without intervention, indicating the medication’s local immunologic activity rather than systemic toxicity or hemolytic reaction.
A: Fever Fever is not typically associated with RhoGAM administration, as it does not cause systemic infection or significant inflammatory responses leading to elevated body temperature.
B: Flank pain Flank pain signifies renal complications such as hemolysis or kidney injury, which are not expected responses following RhoGAM, a preventive immunoglobulin, especially in Rh-positive clients.
C: Dark-colored urine Dark-colored urine indicates hemolysis or blood breakdown, conditions not triggered by RhoGAM administration in Rh-positive individuals; this symptom suggests serious reactions unrelated to expected local injection effects.
The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth.
Rationale:
The nurse should administer 0.25 mL of vitamin K to the newborn.
This calculation is based on the ordered dose of 0.5 mg and the available concentration of 2 mg/mL. Dividing 0.5 mg by 2 mg/mL yields 0.25 mL, ensuring the newborn receives the precise prescribed amount safely and accurately.
B: 0.50 mL corresponds to 1 mg of vitamin K, doubling the intended dose and risking overdose.
C: 1.00 mL equals 2 mg, which is four times the prescribed amount, significantly exceeding the required dose for the newborn.
D: 2.00 mL represents 4 mg, an excessive dose that could lead to serious complications in the infant.
A female African American baby has been admitted into the nursery. Which of the following physiological findings would the nurse assess as normal?Select one that doesn't apply
Rationale:
A sharply demarcated dark red area on the face is not a normal physiological finding in a female African American newborn.
This option is incorrect because sharply demarcated dark red areas suggest a possible port-wine stain or vascular malformation, which is not a typical normal variation in newborns. Normal findings usually include transient and benign features rather than sharply outlined vascular lesions.
A: Purple-colored patches on the buttocks and torso represent Mongolian spots, a common, benign pigmentation in African American infants and are considered normal physiological findings.
B: Bilateral whitish discharge from the breasts reflects neonatal mastitis or milk secretion due to maternal hormones, which is a normal transient condition in newborns.
C: Bloody discharge from the vagina, also known as pseudomenstruation, occurs due to maternal hormone withdrawal and is a normal transient finding in female neonates.
A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
Rationale:
Magnesium 7 mg/dL should be reported to the surgeon. Elevated magnesium levels indicate possible magnesium toxicity, especially in a client receiving magnesium sulfate, which can depress respiratory and cardiac function. Prompt notification allows for timely intervention to prevent complications such as respiratory paralysis or cardiac arrest. Monitoring magnesium is critical after eclampsia treatment to ensure patient safety and avoid overdose effects.
B: Sodium 136 mg/dL falls within the normal range (135-145 mEq/L), indicating no immediate electrolyte imbalance related to sodium levels, so it does not require reporting.
C: Potassium 3.0 mg/dL is slightly low but not critically dangerous; mild hypokalemia is common postoperatively and often monitored without urgent intervention.
D: Calcium 9 mg/dL is within normal serum calcium limits (8.5-10.5 mg/dL) and does not suggest any acute abnormalities needing surgical notification.
On admission to the labor and delivery suite, the nurse assesses the discharge needs of a primipara who will be discharged home 4 days after a cesarean delivery. Which of the following questions should the nurse ask the client?
Rationale:
The nurse should ask, "Are there many stairs in your home?" to assess potential mobility challenges after a cesarean delivery. This question helps identify environmental barriers that may affect the client’s safety and ability to navigate daily activities during recovery, enabling tailored discharge planning and support to prevent falls or complications related to limited physical mobility post-surgery.
A: Have you ever had anesthesia before? This question pertains to anesthesia history but does not directly address immediate discharge needs or home safety for a post-cesarean recovery, making it less relevant for discharge planning.
B: Do you have any allergies? Important for medical history but unrelated to assessing home environment or functional limitations impacting discharge after cesarean surgery.
C: Do you scar easily? While scar formation is a concern, it does not provide critical information about the client’s immediate physical environment or ability to manage daily tasks post-discharge.
The nurse is teaching a non - breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.)
Rationale:
Avoid massaging the breasts. Massaging stimulates milk production and can increase discomfort or engorgement, so avoiding this action helps suppress lactation effectively. Non-breastfeeding patients benefit from minimizing stimulation to reduce milk supply and ease breast tenderness during the involution process, preventing unnecessary milk secretion and promoting comfort.
B: Allow warm shower water to run over the breasts. Warm water encourages blood flow and milk production, thus increasing lactation instead of suppressing it, which contradicts the goal of decreasing milk supply in non-breastfeeding patients.
C: If the breasts become engorged, pumping is recommended. Pumping stimulates milk removal, promoting continued lactation rather than suppression, which is counterproductive for patients aiming to stop milk production.
D: Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort. Although these reduce pain and swelling, they do not actively suppress lactation, serving only as symptomatic relief rather than a method to inhibit milk production.
A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
Rationale:
Bright red hemorrhages in the sclerae of a newborn’s eyes are commonly caused by pressure changes during birth and typically resolve without intervention.
The hemorrhages result from fragile blood vessels rupturing due to the stress of delivery, making reassurance appropriate as they are benign and self-limiting. Immediate invasive actions or assumptions of abuse are unnecessary unless additional symptoms arise, ensuring calm and accurate nursing care.
A: Notifying the pediatrician immediately is premature without further assessment or signs of distress, as these hemorrhages are usually harmless and self-resolving.
B: Alerting the social worker for probable abuse disregards the common, natural cause of birth-related scleral hemorrhages and could cause unwarranted distress or investigation.
D: Using an ophthalmoscope to evaluate the retina is excessive since scleral hemorrhages do not typically affect the retina or red reflex, and no visual impairment is indicated.
A breastfeeding mother mentions to the nurse that she has heard that babies sleep better at night if they are given a small amount of rice cereal in the evening. Which of the following comments by the nurse is appropriate?
Rationale:
Breastfed babies should receive only breast milk for the first 4 to 6 months of life. This recommendation supports optimal nutrition, immune protection, and digestive development, avoiding early introduction of solids like rice cereal that can increase allergy risk and interfere with breastfeeding benefits. Exclusive breastfeeding promotes healthy growth and reduces illness during this critical early period.
A: That rice cereal does not reliably improve sleep quality and may pose digestive or allergy concerns when introduced prematurely. This statement inaccurately simplifies infant digestion and sleep patterns.
C: Saying it is too early for rice cereal lacks precision; the emphasis is on exclusive breastfeeding for 4 to 6 months rather than just timing.
D: Suggesting apple sauce or juice at 3 or 4 months contradicts guidelines and introduces inappropriate solids or liquids too early, risking nutritional imbalance and potential harm.
What type of lochia is bright to dark red and occurs on days 1 - 3 postpartum?
Rationale:
Lochia rubra is bright to dark red and occurs on days 1 - 3 postpartum. Lochia rubra consists mainly of blood, decidual tissue, and mucus, making it distinctly red and heavy during the initial postpartum days as the uterus sheds its lining. This phase reflects the body's natural healing and cleansing process immediately after childbirth.
B: Serosa represents a later stage of lochia, characterized by pinkish or brownish discharge, occurring typically from days 4 to 10 postpartum, not the initial bright red phase.
C: Placental lochia is not a recognized term for postpartum vaginal discharge, thus it does not describe the red bleeding seen in early postpartum days.
D: Alba is the final stage of lochia, marked by white or yellowish discharge, appearing after the rubra and serosa phases, not during days 1 to 3 postpartum.
What theory developed by Ramona Mercer focused on the process of becoming a mother?
Rationale:
Maternal Role Attainment is the theory developed by Ramona Mercer that focused on the process of becoming a mother. This theory describes how women gradually assume their maternal role through stages involving learning, adjustment, and integration of mothering behaviors, emphasizing personal and social development during early motherhood. Mercer’s work highlights the psychological and emotional growth essential in becoming a confident and competent mother.
B: Postpartum Adapting does not exist as a recognized theory by Mercer regarding motherhood; it inaccurately suggests only adjustment after birth without addressing the developmental process of becoming a mother.
C: Postpartum Maternal Change misrepresents Mercer’s focus by implying general changes after birth rather than the specific process of maternal role acquisition and identity formation.
D: Maternal Encouragement inaccurately attributes Mercer’s theory to a concept of external support rather than the internal psychological process central to becoming a mother.
The nursery nurse is careful to wear gloves when admitting neonates into the nursery. Which of the following is the scientific rationale for this action?
Rationale:
Wearing gloves when admitting neonates is because meconium is filled with enteric bacteria. This precaution prevents transmission of potentially pathogenic bacteria from meconium to healthcare workers or other infants. Meconium, the newborn’s first stool, harbors microbes that could cause infections if contacted directly. Gloves act as a barrier, maintaining hygiene and reducing cross-contamination risks in the nursery environment.
B: Amniotic fluid may carry some viruses, but it is not the primary reason gloves are worn during admission, as viral transmission risk here is lower compared to bacteria in meconium.
C: Fetal urine’s alkalinity is not sufficiently caustic to harm skin. The use of gloves is unrelated to chemical irritation but focuses on microbial protection against infection.
D: While newborns are vulnerable to infections, the rationale for gloves specifically addresses preventing bacterial exposure from meconium, not general infection risk alone in the baby.
A nurse notes that a 6-hour-old neonate has cyanotic hands and feet. Which of the following actions by the nurse is appropriate?
Rationale:
Swaddle baby in a blanket.
Swaddling a neonate with cyanotic extremities helps maintain body heat and promotes peripheral circulation, which can improve color and warmth in hands and feet. Cyanosis in newborns often results from cold stress rather than hypoxia, so keeping the infant warm is a primary intervention before considering more invasive measures or oxygen administration.
A: Place child in an isolette. Isolette use is more for temperature regulation but does not provide immediate warmth through direct contact, which is more effective in preventing cold-induced cyanosis in newborns.
B: Administer oxygen. Oxygen is not the first-line response for peripheral cyanosis in a stable neonate; unnecessary oxygen can cause oxidative stress and is reserved for systemic hypoxia.
D: Apply pulse oximeter. While monitoring oxygen saturation is useful, applying a pulse oximeter does not address the immediate need to improve peripheral circulation and warmth in cyanotic hands and feet.
A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time?
Rationale:
Reglan (metoclopramide) should be administered to treat postoperative vomiting in a patient who had an epidural. Reglan is an antiemetic that enhances gastric emptying and reduces nausea and vomiting, making it appropriate for managing the patient’s symptoms after surgery. It is effective and commonly prescribed for this indication in the postoperative setting.
B: Demerol (meperidine) is an opioid analgesic primarily used for pain control, not for treating nausea or vomiting, so it does not address the patient’s vomiting episodes.
C: Seconal (secobarbital) is a barbiturate sedative used for anxiety or insomnia, lacking antiemetic properties and thus unsuitable for managing postoperative vomiting.
D: Benadryl (diphenhydramine) is an antihistamine primarily for allergic reactions or motion sickness, but it does not effectively treat postoperative vomiting related to epidural anesthesia.
To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize?
Rationale:
Gently palpate, applying the same technique used for vaginal deliveries. This method ensures careful assessment without causing discomfort or disturbing the surgical site. It allows the nurse to accurately evaluate uterine tone and contraction strength while minimizing risk of infection or injury, maintaining safety and effectiveness consistent with postpartum care standards following cesarean birth.
A: Assess lochial flow rather than palpating the fundus. Lochial flow monitoring alone does not provide direct information about uterine contraction or tone, which is essential for detecting uterine atony or hemorrhage.
B: Palpate forcefully through the abdominal dressing. Forceful palpation risks wound disruption, pain, and infection; it is unsafe and inappropriate for assessing the fundus post-cesarean.
C: Place hands on both sides of the abdomen and press downward. This technique does not effectively isolate or evaluate the fundus and may cause unnecessary discomfort without accurate assessment results.
The nurse administers RhoGAM to a postpartum client. Which of the following is the goal of the medication?
Rationale:
RhoGAM’s goal is to inhibit the mother's active immune response. This medication prevents the mother's immune system from recognizing and attacking Rh-positive fetal red blood cells by neutralizing any fetal Rh-positive cells before they stimulate antibody production, thus avoiding hemolytic disease in future pregnancies by stopping sensitization.
B: Aggressively destroying Rh antibodies is false; RhoGAM prevents antibody formation rather than eliminating antibodies already produced.
C: Preventing fetal cell migration is inaccurate; RhoGAM targets the immune response, not the physical movement of fetal cells.
D: Changing maternal blood type to Rh-positive is incorrect; RhoGAM does not alter blood type but modulates immune sensitization.