Exhibit 1. Exhibit 2. Exhibit 3. Nurses' notes:. Decreased activity level over the last 12 hr. Abdominal distention. Three bloody stools over the last 4 hr. Superficial rash on the abdominal wall. Light palpation of the abdomen leads to fist clenching, thrashing, and crying. A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse take?
Measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr.
Insert an orogastric decompression tube with low wall suction.
Provide the newborn with an iron-rich formula containing vitamin B12 every 2 hr.
Administer nitric oxide inhalation therapy to the newborn.
The Correct Answer is B
Choice A rationale:
The nurse should not measure the abdominal circumference at the level of the newborn's umbilicus every 12 hr because this action does not address the specific problem presented in the scenario, which is abdominal distention and bloody stools. Measuring abdominal circumference is typically done to assess for growth and may not provide valuable information in this situation.
Choice B rationale:
Inserting an orogastric decompression tube with low wall suction is the appropriate action for a newborn with abdominal distension and bloody stools. This intervention can help decompress the gastrointestinal tract, reducing abdominal distention, and possibly preventing further complications.
Choice C rationale:
Providing the newborn with an iron-rich formula containing vitamin B12 every 2 hr is not indicated based on the information provided in the scenario. The newborn's symptoms are suggestive of gastrointestinal issues, and this intervention may not address the underlying cause.
Choice D rationale:
Administering nitric oxide inhalation therapy to the newborn is not appropriate in this context. Nitric oxide inhalation therapy is typically used for conditions like persistent pulmonary hypertension in the newborn, and there is no indication for its use in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B: Administer a bolus infusion of lactated Ringer’s.
Choice A rationale:
Positioning the client in a knee-chest position is not the standard intervention for maternal hypotension following epidural placement. This position is more commonly associated with cord prolapse or to relieve pressure on the vena cava.
Choice B rationale:
Administering a bolus infusion of lactated Ringer’s is the correct action. Hypotension during epidural analgesia is treated with additional intravenous boluses of crystalloid solution. This helps to increase the circulating blood volume and counteract the vasodilation caused by the epidural.
Choice C rationale:
Terbutaline is a medication used to relax the uterus and prevent premature labor, not for treating hypotension.
Choice D rationale:
Applying oxygen via a nonrebreather face mask at 2 L/min is not the primary treatment for maternal hypotension. Oxygen may be used as a supportive measure if there is evidence of fetal distress or maternal hypoxemia, but the first line of treatment for hypotension is fluid administration.
Correct Answer is B
Explanation
Choice A rationale:
Requesting that the provider insert an intrauterine pressure catheter is not the immediate action the nurse should take when the umbilical cord is palpated during a vaginal examination. The priority is to relieve pressure on the cord and improve fetal oxygenation.
Choice B rationale:
Exerting continuous upward pressure on the presenting part is the correct action when the nurse palpates the umbilical cord during a vaginal examination. This manoeuvre is called "vaginal elevation,”. helps lift the presenting part off the umbilical cord, reducing the risk of cord compression and fetal distress until the provider can take further action.
Choice C rationale:
Initiating oxytocin via continuous IV infusion is not appropriate when the umbilical cord is palpated during a vaginal examination. Oxytocin can cause uterine contractions, potentially further compromising the cord and fetus.
Choice D rationale:
Placing the client in the left-lateral position is not the best immediate action for cord palpation. While the left-lateral position is useful for relieving pressure on the vena cava in cases of supine hypotensive syndrome, the priority here is to relieve cord compression, and upward pressure on the presenting part is more effective.
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