A nurse is planning care for a newborn who has spinal bifida.
Which of the following actions should be included in the plan of care?

Obtain rectal temperatures

Cover the lesion with a dry dressing

Apply snug clean diapers

Place the newborn in the prone position .

Answer and Explanation

The Correct Answer is D

Choice A rationale

Obtaining rectal temperatures is not recommended for newborns with spinal bifida. This is because the rectal route can introduce bacteria into the body, which can lead to infection.

Additionally, the rectal route may not provide an accurate temperature reading for these newborns.

Choice B rationale

Covering the lesion with a dry dressing is not recommended for newborns with spinal bifida. The lesion should be kept moist to prevent drying and cracking, which can lead to infection.

Choice C rationale

Applying snug clean diapers is not recommended for newborns with spinal bifida. This is because the pressure from the diaper can damage the exposed nerves and tissues in the lesion area.

Choice D rationale

Placing the newborn in the prone position is recommended for newborns with spinal bifida. This position helps to minimize pressure on the lesion and reduces the risk of trauma and infection.

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Correct Answer is C

Explanation

The correct answer is Choice C. . . However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice B rationale

Applying a fetal scalp electrode is a procedure used for continuous fetal heart monitoring during labor. It provides a more accurate and consistent transmission of the fetal heart rate than external methods. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

Choice C rationale

Changing the client’s position can help improve uteroplacental blood flow and fetal oxygenation. It is often the first action taken when late decelerations are noted in the FHR.

Choice D rationale

Increasing the rate of the IV infusion can help increase maternal blood volume and improve uteroplacental blood flow. However, it is not the first action a nurse should take when late decelerations in the FHR are noted.

A. Hyperinsulinemia B. Increased blood viscosity C. Brachial plexus injury D. Increased deposits of fat in the chest and shoulder areas

Correct Answer is A

Explanation

Choice A rationale

This is the correct answer. In infants of mothers with poorly controlled diabetes, hyperinsulinemia can lead to increased oxygen consumption and metabolic rate, which can contribute to the development of respiratory distress syndrome.

Choice B rationale

Increased blood viscosity is not the most likely cause of respiratory distress in a macrosomic newborn of a mother with poorly controlled diabetes.

Choice C rationale

A brachial plexus injury is a potential complication of delivery for macrosomic infants, but it is not a cause of respiratory distress syndrome.

Choice D rationale

Increased deposits of fat in the chest and shoulder areas can make delivery more difficult and can increase the risk of birth injuries, but they are not the most likely cause of respiratory distress syndrome in a macrosomic newborn of a mother with poorly controlled diabetes.

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A nurse is planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a term macrosomic newborn whose mother has poorly controlled type 2 diabetes. The newborn has respiratory distress syndrome. The nurse should be aware that the most likely cause of the respiratory distress is which of the following?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is planning care for a newborn who has spinal bifida.
Which of the following actions should be included in the plan of care?