A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and feet that are cool and
slightly blue What action should the nurse take?
... [Show More] a. check the newborns temp using temporal thermometer
b. place the naked newborn on the mothers bare chest and cover both with a blanket
c. apply an o2 hood over the newborns head and neck
d. give the newborn glucose water between feedings - b. place the naked newborn on the mothers bare
chest and cover both with a blanket
Exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish
discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and
A nurse is caring for a newborn immediately following delivery. What actions should the nurse take
a. place the newborn directly on the client's chest
b. administer erythromycin ophthalmic ointment
c. give the newborn vit K IM
d. perform a detailed physical assessment - a. place the newborn directly on the client's chest
The nurse should apply the safety and risk reduction priority-setting framework when caring for this
client. This framework assigns priority to the factor or situation posing the greatest safety risk to the
client. When there are several risks to client safety, the 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 planning care for a newborn who is receiving phototherapy for an elevated bilirubin level.
What action should the nurse take?
a. apply barrier ointment to the newborn's perianal regionb. offer the newborn glucose water between feedings
c. use photometer to monitor the lamp's energy
d. keep the newborn's eye patches on during feedings - c. use photometer to monitor the lamp's energy
the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving
the appropriate amount to be effective
A nurse is providing teaching to the parents of a newborn about home safety. What statement by the
parents indicates an understanding of the teaching?
a. I will use an infant carrier when I drive to places close to the house
b. I will tie my baby's pacifier around his neck with a piece of yarn
c. I will place my baby on his back when it is time for him to sleep
d. I will keep my babys crib close to heat vents to keep him warm - c. I will place my baby on his back
when it is time for him to sleep
The newborn should always sleep on his back to prevent sudden infant death syndrome.
A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp 36, well flexed
extremities, responding to stimuli with a cry, blue hands and feet. What Apgar score should the nurse
assign to the newborn?
d. 7 - b. 9
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 to each of five categories. The nurse
should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry,
which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected
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 hr postpartum and has a 3rd degree perineal laceration. The
client's temp is 37.8 C (100F), her fundus is firm and slightly deviated to the right. The client reports a
gush of blood when she ambulates and no bm since delivery. What action should the nurse take?
a. notify the provider about the elevated temp
b. massage the client's fundus
c. administer bisacodyl supp
d. assist the client to empty her bladder - d. assist the client to empty her bladder
When the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse
should assist the client to empty her bladder to prevent uterine atony and excessive lochia.
A nurse is preparing to administer morphine oral solution 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? - 0.25
A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow respirations and
periods of apnea lasting up to 10 seconds. What action should the nurse take?
a. continue routine monitoring
b. place newborn prone
c. request a script for supplemental o2
d. perform chest percussion - [Show Less]