A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

Instruct the mother to delay breastfeeding for 1 week.

Initiate airborne precautions.

Wait at least 24 hr before bathing the newborn.

Administer hepatitis B immune globulin IM to the newborn.

Answer and Explanation

The Correct Answer is D

A. Breastfeeding is not contraindicated in mothers with hepatitis B if the newborn receives appropriate prophylaxis.
B. Airborne precautions are not necessary; hepatitis B is transmitted through blood and body fluids, not airborne droplets.
C. Bathing the newborn does not affect hepatitis B transmission risk and does not need to be delayed.
D. Administering hepatitis B immune globulin (HBIG) IM to the newborn within 12 hours of birth, along with the first dose of the hepatitis B vaccine, is essential to prevent vertical transmission of hepatitis B virus.

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Correct Answer is C

Explanation

A. Hypotension, not hypertension, is expected in hemorrhagic shock due to blood loss.
B. Tachypnea, not bradypnea, usually occurs as the body tries to compensate for hypoxia.
C. Tachycardia is an early compensatory response to blood loss to maintain cardiac output.
D. Oliguria (decreased urine output), not polyuria, is expected due to poor perfusion of kidneys in shock.

A. Maternal Rh factor B. Gestational age C. Apgar scores D. Weight E. Type of birth F. Length

Correct Answer is ["B","E"]

Explanation

A. Maternal Rh factor – The mother is O positive. Rh incompatibility is not a concern here because both mother and newborn are likely Rh positive, and no information suggests Rh incompatibility.
B. Gestational age – The newborn was born at 36 weeks and 4 days, which is considered late preterm and places the infant at increased risk for complications such as respiratory distress, jaundice, hypoglycemia, and feeding difficulties.
C. Apgar scores – Scores of 7 at 1 minute and 8 at 5 minutes are within the normal range and not indicative of distress or a complication risk.
D. Weight – A birth weight of 3,062 g (6 lb 12 oz) is appropriate for gestational age and not a risk factor.
E. Type of birth – Operative vaginal birth using a vacuum extractor increases the risk for complications like cephalohematoma, which is noted in the assessment (firm, edematous scalp area with ecchymosis not crossing suture lines). This can contribute to jaundice.
F. Length – A length of 48 cm (19 in) is appropriate for gestational age and not a risk factor.

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A nurse is preparing the plan of care for a term newborn who was asymptomatic at birth and whose mother had hepatitis B during pregnancy. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postpartum and is experiencing hemorrhagic shock. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a newborn Exhibits Which findings are risk factors for the newborn to develop a complication? Select all that apply

Correct Answer is ["B","E"]

Explanation

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