The nurse is caring for a primigravida client who delivered vaginally 48-hours ago.The client's laboratory results are: hemoglobin 12 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus negative. Which prescription should the nurse prepare to administer?

Blood transfusion.

Rubella vaccination.

Penicillin G potassium.

Hepatitis B immunoglobulin.

Answer and Explanation

The Correct Answer is B

Choice A rationale

The client has a hemoglobin level of 12 g/dL and a hematocrit of 34%, which are within normal ranges for a postpartum woman. A blood transfusion is typically indicated for severe anemia or significant blood loss, neither of which is suggested by these lab results. Therefore, a blood transfusion is not warranted in this case.

Choice B rationale

Rubella vaccination is indicated for a client who is non-immune to rubella, as indicated by the laboratory results. Rubella vaccination is important to protect the client from contracting rubella in future pregnancies, which can cause serious congenital defects. Since the client is not currently pregnant and not immune, vaccination can be safely administered postpartum to prevent future rubella infections.

Choice C rationale

Penicillin G potassium is an antibiotic that might be used for a client who is group B Streptococcus positive to prevent neonatal infection during delivery. However, this client is group B Streptococcus negative, so there is no indication for this antibiotic. There is no need to administer Penicillin G potassium in this scenario.

Choice D rationale

Hepatitis B immunoglobulin is used for newborns of mothers who are hepatitis B surface antigen positive to prevent perinatal transmission of the virus. Since the client's lab results indicate she is hepatitis B surface antigen negative, there is no need for Hepatitis B immunoglobulin. The client and her newborn are not at risk of hepatitis B transmission, so this intervention is not required. .

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Correct Answer is D

Explanation

Choice A rationale

Blow-by oxygen delivery can provide some additional oxygen to the apneic newborn, but it may not be effective in stimulating breathing or providing adequate ventilation. It is a less direct method of addressing apnea compared to positive pressure ventilation.

Choice B rationale

Starting an IV infusion in a scalp vein is important for medication administration or fluid resuscitation but is not the immediate priority for a newborn who is apneic and has a heart rate of 100 beats per minute. Establishing adequate ventilation takes precedence to ensure oxygenation and stabilize the newborn.

Choice C rationale

Assisting the neonatologist with intubation may be necessary if positive pressure ventilation is unsuccessful or if there are signs of severe respiratory distress. However, the immediate next step for an apneic newborn with a heart rate of 100 beats per minute should be to provide positive pressure ventilation to stimulate breathing.

Choice D rationale

Providing positive pressure ventilation is the recommended immediate action for a newborn who remains apneic and has a heart rate of less than 100 beats per minute. This intervention helps to inflate the lungs, establish effective breathing, and improve oxygenation, which is critical for the newborn's survival.

A. Ventricular septal defect (VSD) has audible murmurs. B. Patent ductus arteriosus is fatigued after feeding C. Coarctation of aorta has an elevated blood pressure in the upper extremity. D. Tetralogy of Fallot (TOF) with hypercyanotic (Tet) spells is crying.

Correct Answer is D

Explanation

Choice A rationale

An audible murmur in a neonate with a ventricular septal defect (VSD) is a common finding and does not typically require immediate intervention. While it indicates a cardiac anomaly, it is not an emergency.

Choice B rationale

Fatigue after feedings in a neonate with patent ductus arteriosus (PDA) is a sign of increased cardiac workload, but it does not indicate an immediate life-threatening situation. It requires monitoring but not urgent intervention.

Choice C rationale

Elevated blood pressure in the upper extremity in a neonate with coarctation of the aorta is a concerning finding that indicates a narrowing of the aorta. While it requires prompt evaluation and management, it may not be as immediately critical as a hypercyanotic spell.

Choice D rationale

A neonate with Tetralogy of Fallot (TOF) experiencing hypercyanotic (Tet) spells and crying indicates a severe decrease in oxygenation and is an emergency. This condition requires immediate intervention to improve oxygenation and prevent complications such as brain damage or death. .

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Naxlex Comprehensive Predictor Exams

Following a vaginal delivery, the nurse places the neonate under the radiant warmer to elicit spontaneous respirations. The newborn has a heart rate of 100 beats per minute and remains apneic when the nurse flicks the soles of the feet. Which action should the nurse implement next?

Correct Answer is D

Explanation

The nurse who is working on a pediatric unit receives a shift report for four neonates with congenital heart defects. The neonate with which report requires the most immediate intervention?

Correct Answer is D

Explanation

A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?

A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include?

A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to his mother when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

The nurse is preparing to administer oxytocin IV to a client after the delivery of her infant. Which outcome should the nurse expect from the administration of oxytocin?

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents.The child is anxious, has a temperature of 102.8°F (39.3°C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?

The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?