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, Terms in this set (30)
A nurse is planning care for a newborn who is receiving 4. Use photometer to monitor the lamp's energy.
phototherapy for an elevated bilirubin level. What action
should the nurse take? Rationale:
The nurse should monitor the lamp's energy throughout the therapy to ensure the
1. Offer the newborn glucose water between feedings. newborn is receiving the appropriate amount to be effective.
2. Keep the newborn's eye patches on during feedings.
3. Apply barrier ointment to the newborn's perianal region.
4. Use photometer to monitor the lamp's energy.
A nurse is assessing a 4-hour old newborn who is to 3. Place the naked newborn on the mother's bare chest and cover both with a blanket.
breastfeed and notes hands and feet that are cool and
slightly blue. What action should the nurse take? Rationale:
Exposure to a cool environment causes vasoconstriction, which results in cool
1. Apply an o2 hood over the newborns head and neck. extremities with a bluish discoloration. Placing the newborn skin-to-skin with his
2. Check the newborns temp using temporal thermometer mother helps stabilize his temperature and promotes bonding.
3. Place the naked newborn on the mother's bare chest and
cover both with a blanket.
4. Give the newborn glucose water between feedings.
A nurse is caring for a newborn immediately following 2. Place the newborn directly on the client's chest.
delivery. What actions should the nurse take first?
Rationale:
1. Perform a detailed physical assessment. The nurse should apply the safety and risk reduction priority-setting framework when
2. Place the newborn directly on the client's chest. caring for this client. This framework assigns priority to the factor or situation posing
3. Give the newborn vitamin K IM. the greatest safety risk to the client. When there are several risks to client safety, the
4. Administer erythromycin ophthalmic ointment. one posing the greatest threat is the highest priority. The nurse should use Maslow's
Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client. Therefore, the greatest risk
to the newborn is cold stress, which increases the need for oxygen and glucose.
Placing the newborn directly on the client's chest will help maintain the newborn's
temperature.
A nurse is providing teaching to the parents of a newborn 1. "I will place my baby on his back when it is time for him to sleep."
about home safety. What statement by the parents indicates
an understanding of the teaching? Rationale:
The newborn should always sleep on his back to prevent sudden infant death
1. "I will place my baby on his back when it is time for him to syndrome.
sleep."
2. "I will keep my baby's crib close to heat vents to keep him
warm."
3. "I will use an infant carrier when I drive to places close to
the house."
4.. "I will tie my baby's pacifier around his neck with a piece
of yarn."
A nurse is assessing a newborn 1 min after birth and notes a 3. 9
heart rate of 136/min, resp 36, well flexed extremities,
responding to stimuli with a cry, blue hands and feet. What Rationale:
Apgar score should the nurse assign to the newborn? The nurse should use the Apgar scoring system to perform a quick assessment of the
newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2
1. 7 to each of five categories. The nurse should assign a score of 2 for a heart rate
2. 8 greater than 100/min; a score of 2 for a good, strong cry, which shows normal
3. 9 respiratory effort; a score of 2 for well flexed extremities, which shows expected
4. 10 normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or
sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.
A nurse is assessing a client who is 14 hours postpartum 2. Assist the client to empty her bladder.
and has a third degree perineal laceration. The client's temp
is 37.8 C (100F), her fundus is firm and slightly deviated to Rationale:
the right. The client reports a gush of blood when she When the client's fundus is deviated to the right or left it can indicate that her bladder
ambulates and no bm since delivery. What action should the is full. The nurse should assist the client to empty her bladder to prevent uterine atony
nurse take? and excessive lochia.
1. Notify the provider about the elevated temperature.
2. Assist the client to empty her bladder.
3. Administer bisacodyl suppository.
4. Massage the client's fundus.
A nurse is preparing to administer morphine oral solution 0.25
0.04 mg/kg to a newborn who weighs 2.5kg. The amount
available is 0.4 mg/ml. how many ml should the nurse
administer?
A nurse is assessing a 12-hour old newborn and notes a 3. Continue routine monitoring.
resp rate of 44 with shallow respirations and periods of
apnea lasting up to 10 seconds. What action should the Rationale:
nurse take? The nurse should continue routine monitoring because the newborn's assessment
findings indicate he is adapting to extrauterine life.
1. Perform chest percussion.
2. Place newborn prone position.
3. Continue routine monitoring.
4. Request a script for supplemental oxygen.
A
TI
R
N
L
e
a
r
ni
n
g
S
y
st
e
m
s
M
at
e
r
n
al
N
e
w
b
o
r
n
P
r
a
ct
ic
e
Q
ui
z
2
Students
also
studied
, Terms in this set (30)
A nurse is planning care for a newborn who is receiving 4. Use photometer to monitor the lamp's energy.
phototherapy for an elevated bilirubin level. What action
should the nurse take? Rationale:
The nurse should monitor the lamp's energy throughout the therapy to ensure the
1. Offer the newborn glucose water between feedings. newborn is receiving the appropriate amount to be effective.
2. Keep the newborn's eye patches on during feedings.
3. Apply barrier ointment to the newborn's perianal region.
4. Use photometer to monitor the lamp's energy.
A nurse is assessing a 4-hour old newborn who is to 3. Place the naked newborn on the mother's bare chest and cover both with a blanket.
breastfeed and notes hands and feet that are cool and
slightly blue. What action should the nurse take? Rationale:
Exposure to a cool environment causes vasoconstriction, which results in cool
1. Apply an o2 hood over the newborns head and neck. extremities with a bluish discoloration. Placing the newborn skin-to-skin with his
2. Check the newborns temp using temporal thermometer mother helps stabilize his temperature and promotes bonding.
3. Place the naked newborn on the mother's bare chest and
cover both with a blanket.
4. Give the newborn glucose water between feedings.
A nurse is caring for a newborn immediately following 2. Place the newborn directly on the client's chest.
delivery. What actions should the nurse take first?
Rationale:
1. Perform a detailed physical assessment. The nurse should apply the safety and risk reduction priority-setting framework when
2. Place the newborn directly on the client's chest. caring for this client. This framework assigns priority to the factor or situation posing
3. Give the newborn vitamin K IM. the greatest safety risk to the client. When there are several risks to client safety, the
4. Administer erythromycin ophthalmic ointment. one posing the greatest threat is the highest priority. The nurse should use Maslow's
Hierarchy of Needs, the ABC priority-setting framework, or nursing knowledge to
identify which risk poses the greatest threat to the client. Therefore, the greatest risk
to the newborn is cold stress, which increases the need for oxygen and glucose.
Placing the newborn directly on the client's chest will help maintain the newborn's
temperature.
A nurse is providing teaching to the parents of a newborn 1. "I will place my baby on his back when it is time for him to sleep."
about home safety. What statement by the parents indicates
an understanding of the teaching? Rationale:
The newborn should always sleep on his back to prevent sudden infant death
1. "I will place my baby on his back when it is time for him to syndrome.
sleep."
2. "I will keep my baby's crib close to heat vents to keep him
warm."
3. "I will use an infant carrier when I drive to places close to
the house."
4.. "I will tie my baby's pacifier around his neck with a piece
of yarn."
A nurse is assessing a newborn 1 min after birth and notes a 3. 9
heart rate of 136/min, resp 36, well flexed extremities,
responding to stimuli with a cry, blue hands and feet. What Rationale:
Apgar score should the nurse assign to the newborn? The nurse should use the Apgar scoring system to perform a quick assessment of the
newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2
1. 7 to each of five categories. The nurse should assign a score of 2 for a heart rate
2. 8 greater than 100/min; a score of 2 for a good, strong cry, which shows normal
3. 9 respiratory effort; a score of 2 for well flexed extremities, which shows expected
4. 10 normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or
sneeze; and a score of 1 for blue hands and feet, known as acrocyanosis.
A nurse is assessing a client who is 14 hours postpartum 2. Assist the client to empty her bladder.
and has a third degree perineal laceration. The client's temp
is 37.8 C (100F), her fundus is firm and slightly deviated to Rationale:
the right. The client reports a gush of blood when she When the client's fundus is deviated to the right or left it can indicate that her bladder
ambulates and no bm since delivery. What action should the is full. The nurse should assist the client to empty her bladder to prevent uterine atony
nurse take? and excessive lochia.
1. Notify the provider about the elevated temperature.
2. Assist the client to empty her bladder.
3. Administer bisacodyl suppository.
4. Massage the client's fundus.
A nurse is preparing to administer morphine oral solution 0.25
0.04 mg/kg to a newborn who weighs 2.5kg. The amount
available is 0.4 mg/ml. how many ml should the nurse
administer?
A nurse is assessing a 12-hour old newborn and notes a 3. Continue routine monitoring.
resp rate of 44 with shallow respirations and periods of
apnea lasting up to 10 seconds. What action should the Rationale:
nurse take? The nurse should continue routine monitoring because the newborn's assessment
findings indicate he is adapting to extrauterine life.
1. Perform chest percussion.
2. Place newborn prone position.
3. Continue routine monitoring.
4. Request a script for supplemental oxygen.
