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

The newborn should be placed in prone position to prevent pressure to the lesion which may lead to damage to the contents of the sac. It should be covered with a sterile, wet gauze to maintain the integrity of the sac.

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Correct Answer is C

Explanation

A blood pressure of 80/56 indicates hypotension. Hypotension is a common complication associated with epidural anesthesia in labor. When the epidural anesthesia is administered, it can cause vasodilation, which can lead to a decrease in blood pressure. This decrease in blood pressure can result in hypotension.

A. A client who is at 28 weeks of gestation and reports of painless vaginal bleeding B. A client who has missed a period and reports vaginal spotting C. A client who is at 14 weeks of gestation and reports nausea and vomiting D. A client who is at 38 weeks of gestation and reports a cough and fever

Correct Answer is A

Explanation

Painless vaginal bleeding in the third trimester could be a sign of placenta previa or placental abruption, both of which are serious conditions requiring immediate medical attention. This client should be seen first due to the potential urgency of the situation.
B. Vaginal spotting in early pregnancy may indicate implantation bleeding or other benign causes, but it could also be a sign of threatened miscarriage or ectopic pregnancy. While this client needs assessment, it's not as urgent as antepartum hemorrhage.
C. A client who is at 14 weeks of gestation and reports nausea and vomiting:

Nausea and vomiting are common symptoms in early pregnancy and typically do not require urgent intervention unless severe dehydration or hyperemesis gravidarum is present.
D. A cough and fever in late pregnancy may indicate a respiratory infection or another illness, but it does not pose an immediate threat to maternal or fetal health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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