A nurse is caring for the newborn 1 day after birth
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. Inactivated influenza vaccine is safe and recommended during pregnancy to protect both mother and fetus.
B. Human papillomavirus (HPV) vaccine is not recommended during pregnancy.
C. Measles, mumps, and rubella (MMR) vaccine is a live vaccine and contraindicated during pregnancy.
D. Varicella vaccine is live and contraindicated during pregnancy.
E. The Tdap vaccine (diphtheria, acellular pertussis, tetanus) is recommended during each pregnancy, ideally between 27 and 36 weeks gestation to protect the newborn from pertussis.
Correct Answer is B
Explanation
A. Ondansetron is used to treat nausea but is not a routine pre-epidural intervention.
B. Administering an IV fluid bolus before epidural anesthesia helps prevent hypotension caused by sympathetic blockade.
C. Epidurals can be administered earlier than 7 cm dilation based on maternal request and clinical assessment.
D. Oxygen administration is not routinely required before an epidural unless fetal distress or maternal hypoxia is present.
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