A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

Obtain rectal temperatures.

Cover the lesion with a dry dressing

Apply snug, clean diapers.

Place the newborn in the prone position.

Answer and Explanation

The Correct Answer is D

The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.

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Correct Answer is B

Explanation

A. The client is experiencing postpartum depression. A prescription of antidepressants is important but should come after fully assessing the client's mental state
B. Asking the client if she has considered harming her newborn is important in further assessments to establish the mothers as it is a common feature of postpartum depression.
C. While reinforcing education on postpartum and newborn care is important for overall maternal and infant well-being, it may not directly address the client's current mental health concerns.
D. Exploring options on how to help the client is key but this should comer after a thorough examination has occurred.

A. Turn the client onto her side. B. Increase the client's IV fluid infusion rate. C. Palpate the client's uterus. D. Administer oxygen to the client. E. Administer oxygen to the client.

Correct Answer is A

Explanation

Late decelerations on the fetal monitor tracing indicate uteroplacental insufficiency, which can compromise fetal oxygenation. When membranes rupture and late decelerations occur, it's essential to take immediate action to improve fetal oxygenation.
Turning the client onto her side can help improve uteroplacental perfusion by relieving pressure on the vena cava and increasing blood flow to the uterus. This is the initial recommended intervention to optimize fetal oxygenation in the presence of late decelerations.
B. Increasing IV fluid infusion rate may be considered to optimize maternal hydration and potentially improve uteroplacental perfusion. However, it may not be the first action taken in response to late decelerations.
C. Palpating the client's uterus can provide information about uterine activity and may help assess for uterine hyperstimulation, which can contribute to fetal distress. However, in the context of late decelerations, the priority is to address potential uteroplacental insufficiency and optimize fetal oxygenation.
D. Administering oxygen to the client helps increase maternal oxygenation, which in turn improves fetal oxygenation. Oxygen administration is done after positing the client on to the lateral position.

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A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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