To protect newborns from infection while in the nursery, the nurse plans to:

Adjust room temperature between 75°F and 80°F

Wear a disposable gown when giving infant care

Keep the newborn dressed warmly

Wash hands before touching each baby

Answer and Explanation

The Correct Answer is D

Wash hands before touching each baby. This is because hand hygiene is the most effective way to prevent infection transmission in the nursery. Hand hygiene should be performed before and after every patient contact, as well as before and after wearing gloves or handling equipment. Hand hygiene can be done by washing hands with soap and water or using alcohol-based hand rubs.

Choice A is not correct because adjusting room temperature between 75°F and 80°F is not a measure to protect newborns from infection. The room temperature should be maintained within a comfortable range for newborns, but it does not affect infection risk.

Choice B is not correct because wearing a disposable gown when giving infant care is not a measure to protect newborns from infection. Disposable gowns are part of contact precautions, which are used for patients with known or suspected infections that can be transmitted by direct or indirect contact. They are not necessary for routine infant care.

Choice C is not correct because keeping the newborn dressed warmly is not a measure to protect newborns from infection. Keeping the newborn dressed warmly can help prevent heat loss and hypothermia, but it does not affect infection risk.

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Correct Answer is C

Explanation

Administer low concentrations of oxygen. Retinopathy of prematurity (ROP) is a disease of retinal vascular and capillary proliferation affecting premature infants undergoing oxygen therapy. Oxygen treatment results in pathologic growth of vessels in the developing retina that may lead to permanent damage to the retina as well as retinal detachment and macular folds. Administering low concentrations of oxygen can help prevent ROP by reducing the oxygen-induced vasoconstriction and vascular endothelial growth factor (VEGF) expression.

Choice A is not correct because keeping the infant's eyes covered at all times does not prevent ROP. In fact, it may increase the risk of infection or injury to the eyes.

Choice B is not correct because positioning with the head slightly lower than the body does not prevent ROP. It may increase the intracranial pressure and affect the cerebral blood flow.

Choice D is not correct because monitoring arterial oxygen levels with a pulse oximeter does not prevent ROP. It is a useful tool to guide oxygen therapy, but it does not directly affect retinal vascular development.

A. Blood pressure B. Amount of lochia C. Fulness of the bladder D. Level of pain

Correct Answer is C

Explanation

Fullness of the bladder. A boggy uterus with the fundus above the umbilicus and deviated to the side indicates that the uterus is not contracting properly and may be displaced by a full bladder. A full bladder can interfere with uterine involution and increase the risk of postpartum hemorrhage. The nurse should assess the bladder and assist the patient to empty it if needed.

Choice A. Blood pressure is not the next assessment because it is not related to the position and tone of the uterus. Blood pressure may be affected by blood loss, but it is not a priority in this situation.

Choice B. Amount of lochia is not the next assessment because it is not related to the position and tone of the uterus. Lochia may be increased or decreased depending on the uterine contraction, but it is not a priority in this situation.

Choice D. Level of pain is not the next assessment because it is not related to the position and tone of the uterus. Pain may be present due to uterine cramping or other factors, but it is not a priority in this situation.

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To protect newborns from infection while in the nursery, the nurse plans to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To prevent possible retinopathy in a preterm infant requiring oxygen therapy, the nurse will:

Correct Answer is C

Explanation

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess:

Correct Answer is C

Explanation

A nurse is updating the plan of care for a newborn who is undergoing phototherapy. Which of the following actions should the nurse include in the plan?

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify which of the following findings places the client at risk for a postpartum hemorrhage.

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be:

The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms, the nurse should:

The nurse is preparing the nursing care plan for a newborn who was born via cesarean delivery. Which diagnosis should the nurse prioritize?

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve: