A nurse is caring for the newborn 1 day after birth

Exhibits
Select 2 orders which the nurse should anticipate that the provider will prescribe

Supplement feedings with dextrose water

Administer intravenous dextrose

Obtain a total serum bilirubin

Encourage breastfeeding every 2 hr

Prepare for an exchange transfusion

Obtain blood cultures

Answer and Explanation

Correct Answer : C,D

A. Supplement feedings with dextrose water – Dextrose water is not appropriate for newborn feeding. It lacks the necessary calories and nutrients and is not recommended for managing hyperbilirubinemia or hydration.

B. Administer intravenous dextrose – There is no evidence of hypoglycemia or need for IV fluids. This is not indicated based on the current assessment.

C. Obtain a total serum bilirubin – The yellow sclera and cephalohematoma (from vacuum-assisted birth) place the newborn at risk for hyperbilirubinemia. A serum bilirubin level is needed to assess severity.

D. Encourage breastfeeding every 2 hr – This promotes bilirubin excretion through stools and urine, which is essential in managing or preventing jaundice in newborns.

E. Prepare for an exchange transfusion – This is a treatment for severe hyperbilirubinemia or hemolytic disease, and is not indicated at this stage without bilirubin results.

F. Obtain blood cultures – The mother received appropriate intrapartum prophylaxis (2 doses of penicillin G) for GBS. The newborn shows no signs of sepsis (vital signs normal, active, feeding), so cultures are not indicated now.

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Correct Answer is C

Explanation

A. The tape measure should be placed vertically, not horizontally, over the abdomen to measure fundal height accurately.
B. The client should be in a supine position, not left-lateral, during the measurement.
C. Fundal height is measured from the upper border of the symphysis pubis to the upper border of the uterine fundus.
D. A full bladder can distort the measurement, so the client should have an empty bladder before measuring fundal height.

A. Assist the client to empty their bladder. B. Apply oxygen at 2 L/min via nasal canula. C. Massage the client's fundus. D. Prepare to initiate cardiopulmonary resuscitation.

Correct Answer is D

Explanation

A. Emptying the bladder is not a priority during an amniotic fluid embolism (AFE) emergency.
B. Oxygen at 2 L/min is insufficient; high-flow oxygen or intubation may be necessary.
C. Fundal massage is used to control bleeding, not to treat AFE.
D. An amniotic fluid embolism can cause sudden cardiovascular collapse and respiratory failure; preparing to initiate cardiopulmonary resuscitation (CPR) is critical for survival.

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A nurse is caring for the newborn 1 day after birth Exhibits Select 2 orders which the nurse should anticipate that the provider will prescribe

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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

A nurse is caring for the newborn 1 day after birth

Exhibits
Select 2 orders which the nurse should anticipate that the provider will prescribe