A nurse is caring for the newborn 1 day after birth
Supplement feedings with dextrose water
Administer intravenous dextrose
Obtain a total serum bilirubin
Encourage breastfeeding every 2 hr
Prepare for an exchange transfusion
Obtain blood cultures
Correct Answer : C,D
A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.
B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.
C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.
D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.
E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.
F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Hand-to-mouth movements are an early hunger cue as the newborn tries to self-soothe or indicate readiness to feed.
C. Rooting reflex is a classic early sign where the newborn turns their head toward the stimulus (like a nipple) indicating hunger.
D. Sucking motions suggest the newborn is preparing or ready to feed.
A. Consistent crying is a late hunger cue and can indicate distress if earlier cues are missed.
E. The Babinski reflex is a neurological reflex unrelated to hunger cues.
Correct Answer is A
Explanation
A. Administering methylergonovine (Methergine) intramuscularly is appropriate for treating postpartum hemorrhage, as it stimulates uterine contractions to help control bleeding.
B. The knee-chest position is not indicated for postpartum hemorrhage and does not address the underlying cause.
C. Oxygen may be necessary if the client is unstable, but 2 L/min via nasal cannula is not the primary intervention and may not be sufficient in a critical situation.
D. Dextrose water is not appropriate for fluid resuscitation during hemorrhage; isotonic fluids like normal saline or lactated Ringer’s are preferred to restore volume.
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