Clinical Nursing

Moments after birth, a neonate of 32 weeks' gestation develops asphyxia. As the neonatal team starts resuscitation, the nurse must:

A. hyperextend the neonate's neck B. keep the neonate's head in the "sniff" position C. maintain the neonate's head in a neutral position D. turn the neonate's head slightly to one side

Answer: keep the neonate's head in the "sniff" position. Rationale: To open the airway, the nurse must keep the neonate's head in the "sniff" position by extending the neck slightly. Hyperextending the neck, keeping the head in a neutral position, or turning the head to one side wouldn't open the neonate's airway.

Which of the following nursing measures would be appropriate in the care of a client who has hepatic encephalopathy?

A. Encourage fluid intake >1500ml/day. B. Administer opiate analgesics on schedule. C. Monitor vital signs for hypertension. D. Observe for changes in behavior.

Answer: Observe for changes in behavior

Which of the following orders should a nurse question for a client with glaucoma who is scheduled for surgery?

A. Demerol (meperidine) 50 mg IM
B. Atropine sulfate 0.4 mg IM
C. Valium (diazepam) 2 mg IM
D. Phenergan (promethazine) 25 mg IM

Answer:Atropine sulfate 0.4 mg IM

The nurse is assessing a neonate born 1 day ago to a client who smoked one pack of cigarettes daily during pregnancy. Which finding is most common in neonates whose mothers smoked during pregnancy?

A. Postterm birth
B. Large size for gestational age
C. Small size for gestational age
D. Appropriate size for gestational age

Answer: Small size for gestational age

Rationale: Neonates of women who smoked during pregnancy are small for gestational age for two reasons: Nicotine causes vasoconstriction, which reduces blood flow and thus nutrient transfer to the fetus, and smokers are at greater risk for poor nutrition. These neonates are more likely to be preterm than postterm because smoking causes maternal vasoconstriction, decreases placental perfusion, and induces uterine contractions. Large size for gestational age results from increased nutrient transfer to the fetus such as in a neonate who receives excessive glucose from a diabetic mother.

While receiving phototherapy, a newborn begins to have frequent, loose, watery, green stools and is very irritable. The nurse interprets this as which of the following?

A. This is a normal adverse effect of phototherapy.
B. The baby is developing lactose intolerance and needs a soy-based formula.
C. The bilirubin is rising to dangerous levels.
D. The infant may have a malabsorption problem.

Answer: This is a normal adverse effect of phototherapy.

Rationale: Phototherapy increases gastric motility, causing the infant to have many green, watery stools. The increased gastric motility also causes the infant to be irritable. There is no evidence that the newborn has a lactose intolerance or malabsorption problem, nor is there evidence that the newborn's bilirubin levels are rising to dangerous levels.

When assessing a neonate who was born at 30 weeks' gestation, the nurse notes bounding femoral pulses, a palpable thrill over the suprasternal notch, tachycardia, tachypnea, and crackles. The nurse suspects:

A. ventricular septal defect.
B. patent ductus arteriosus.
C. tetralogy of Fallot.
D. atrial septal defect.

Answer: B.patent ductus arteriosus.

Rationale: Patent ductus arteriosus causes tachycardia, tachypnea, a palpable thrill over the suprasternal notch, hepatomegaly, bounding peripheral pulses, widened pulse pressure, a continuous or systolic heart murmur, increased heart pulsation, and signs of respiratory distress or heart failure (such as increasing respiratory effort, crackles or moist breath sounds, feeding intolerance, fatigue, and decreasing urine output). Ventricular and atrial septal defects rarely cause signs at birth, although a neonate with an atrial septal defect may have a systolic murmur. With tetralogy of Fallot, the neonate typically has cyanosis, dyspnea, and a continuous murmur that is audible across the back.

One minute after birth, a neonate has an Apgar score of 7. What should the nurse do?

A. Administer oxygen via nasal prongs as ordered.
B. Begin cardiopulmonary resuscitation (CPR).
C. Stimulate breathing by rubbing the neonate's back.
D. Encourage the mother to hold the neonate close.

Answer: Stimulate breathing by rubbing the neonate's back.

Rationale: An Apgar score of 5 to 7 (out of a total possible score of 10) indicates mild respiratory depression. To correct this problem, the nurse should stimulate breathing by rubbing the neonate's back or by gently but firmly slapping the neonate's soles. The nurse should also provide oxygen (at 100% concentration) but should administer it by bag and face mask rather than nasal prongs. The nurse should perform CPR only if the neonate's Apgar score is between 0 and 2. The neonate must be stabilized before being held by the mother.

A female newborn born by elective cesarean section to a 25-year-old mother weighs 3,500 g . The nurse places the newborn under the warmer unit. In addition to routine assessments, the nurse should closely monitor this newborn for which of the following?

A. Temperature instability due to type of birth
B. Respiratory distress due to lack of contractions
C. Signs of acrocyanosis
D. Unstable blood sugars

Answer: Respiratory distress due to lack of contractions

Rationale: The squeezing action of the contractions during labor enhances fetal lung maturity. Infants who aren't subjected to contractions are at an increased risk for developing respiratory distress. The type of birth has nothing to do with temperature or glucose stability, and acrocyanosis is a normal finding.

What is a common adverse effect of phototherapy?

A. Kernicterus
B. Watery stools
C. Positive Coombs' test
D. Polyuria

Answer: Watery stools

Rationale: Phototherapy involves exposing an infant's bare skin to intense fluorescent light in the treatment of hyperbilirubinemia and jaundice. Watery stools result from excretion of bilirubin. Kernicterus is a complication of jaundice — not phototherapy. Coombs' test is performed to determine the cause of jaundice and is unrelated to phototherapy. Polyuria isn't a result of phototherapy.

Immediately after a delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding?

A. Fetal body flexion or extension
B. Maternal age, body frame, and weight
C. Maternal and paternal ethnic backgrounds
D. Maternal parity and gravidity

Answer: Fetal body flexion or extension

Rationale: Fetal attitude — the overall degree of body flexion or extension — determines the type of molding in the head of a neonate. Molding isn't influenced by maternal age, body frame, weight, parity, or gravidity or by maternal and paternal ethnic backgrounds.