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 choiceB. Decreased ability to bear down.
Choice A rationale:
Fetal bradycardia is not a common adverse effect of a pudendal nerve block.This block primarily affects the mother’s pelvic region and does not typically impact fetal heart rate.
Choice B rationale:
Decreased ability to bear down is correct because the pudendal nerve block can numb the perineal area, reducing the mother’s ability to feel contractions and effectively bear down during labor.
Choice C rationale:
Maternal hypertension is not associated with pudendal nerve blocks.This block is localized and does not generally affect systemic blood pressure.
Choice D rationale:
Uterine hyperstimulation is not a known adverse effect of pudendal nerve blocks.This condition is more commonly associated with the use of labor-inducing drugs like oxytocin.
Correct Answer is C
Explanation
Choice A rationale:
The nurse should not tell the client that she cannot have an amniocentesis until she is at least 35 years of age. Age is not the primary factor for determining the eligibility for an amniocentesis. Amniocentesis is typically performed when there is a medical indication, such as advanced maternal age, abnormal prenatal screening, or a family history of genetic disorders.
Choice B rationale:
The nurse should not schedule the amniocentesis for later today without further clarification from the provider. Scheduling medical procedures without the provider's approval is not within the nurse's scope of practice and could lead to potential risks.
Choice C rationale:
This is the correct answer. The nurse should explain to the client that amniocentesis is a procedure used to determine if the baby has genetic or congenital disorders. It involves the extraction of a small amount of amniotic fluid to analyze the fetal cells for genetic abnormalities.
Choice D rationale:
The nurse should not tell the client that her provider will schedule a chorionic villus sampling (CVS) to determine the sex of the baby. CVS is another prenatal diagnostic test, but its primary purpose is to detect genetic disorders early in pregnancy, not to determine the baby's sex.
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