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 D
Explanation
Choice A rationale:
This statement is incorrect. An indirect Coombs' test is not used to determine the risk of hypoglycemia in a baby after birth. It is used to detect antibodies against red blood cells, particularly in the context of blood incompatibility between a pregnant woman and her fetus.
Choice B rationale:
This statement is incorrect. An indirect Coombs' test is not related to determining the amount of amniotic fluid around the fetus. It is used primarily to assess for Rh incompatibility between the mother and fetus.
Choice C rationale:
This statement is incorrect. The test described here is a Doppler ultrasound, not an indirect Coombs' test. Doppler ultrasound is used to study blood flow in the fetus and placenta using ultrasound waves.
Correct Answer is A
Explanation
Choice A rationale:
Determining gestational age in the first trimester is a common and important use of ultrasound. It helps confirm the estimated due date and monitor the fetus's growth and development.
Choice B rationale:
Performing a biophysical profile in the first trimester is not a common use of ultrasound. Biophysical profiles are usually performed in the second or third trimester to assess fetal well-being.
Choice C rationale:
Observing placental maturity in the first trimester is not a standard use of ultrasound. Placental maturity is typically assessed later in pregnancy, especially in the third trimester.
Choice D rationale:
Detecting intrauterine growth restriction in the first trimester is not a primary use of ultrasound. Intrauterine growth restriction is more commonly assessed in the later stages of pregnancy when fetal growth is a concern.
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