REAL EXAM QUESTIONS WITH ACCURATE VERIFIED
ANSWERS (ACCURATE SOLUTIONS) A+ PASSED!!
A client is admitted in active labor at 39 weeks' gestation.
During the initial examination the nurse identifies multiple red
blister-like lesions on the edges of the client's vaginal orifice.
Once the nurse has spoken to the practitioner and receive
prescriptions, the priority nursing action is:
1
Beginning the IV antibiotic
2
Preparing for a cesarean birth
3
Taking a smear of the lesions for testing
4
Documenting the need for double gloving - ANSWER-2
probably herpes infection
A client who has type O Rh-positive blood gives birth. The
neonate has type B Rh-negative blood. When the nurse
assesses the neonate 11 hours after birth, the infant's skin
appears yellow. What is the most likely cause? 1
,Neonatal sepsis
2
Rh incompatibility
3
Physiologic jaundice
4
ABO incompatibility - ANSWER-4
There is an apparent ABO incompatibility because the mother
is O and the infant is B; incompatibility can cause jaundice
within the first 24 hours. The information provided does not
indicate neonatal sepsis. Rh incompatibility is not a factor
because the mother is Rh positive. Jaundice in the first 24
hours is not physiologic; it is pathologic.
,1
A nurse in the newborn nursery observes a yellowish skin
coloration in an infant
who was delivered in a cesarean birth. What is the immediate
nursing action?
Notifying the health care
provider
Ascertaining how many hours ago the
neonate was born
Taking a heel blood sample and sending it to the
laboratory
Covering the eyes and placing the neonate under high-
intensity ligh -
ANSWER-
2
1
2
3
4
The neonate's age is a critical assessment because the
development of jaundice before 24 to 48 hours have elapsed
, since birth may indicate a blood dyscrasia (pathologic
jaundice, hyperbilirubinemia) requiring immediate
investigation. Jaundice occurring with 48 to 72 hours of birth
(physiologic jaundice) is a consequence of the expected
breakdown of fetal red blood cells and immaturity of the liver.
Unless the jaundice was pathologic (occurring in the first 24
hours of life), this is not necessary. First, the age of the
neonate must be ascertained to determine whether this is
physiologic or pathologic jaundice; next the nurse should
obtain a sample of heel blood to determine the serum bilirubin
level. Bilirubin studies should be performed first to determine
whether the serum level warrants phototherapy. This therapy
requires a health care provider's prescription.
t 1 minute after birth the nurse determines that an infant is
crying, has a heart rate of 140 beats/min, has blue hands and
feet, resists the suction catheter, and keeps the legs flexed and
the arms extended. What Apgar score should the nurse
assign?
1. 6
2. 7
3. 8
4. 9 - ANSWER-3
The Apgar score is 8; 1 point is deducted for diminished
muscle tone (the baby's arms do not flex) and 1 point for