A mother's laboratory results indicate the presence of cocaine and alcohol. The characteristic in her newborn that would indicate to the nurse that the baby has been affected with fetal alcohol syndrome would be:

Correct Answer: D

Rationale: The order that the nurse should question is "Ampicillin 200mg./kg IV every 6 hours." The usual dosage for ampicillin is 200-300 mg/kg/day divided into 4-6 doses, not every 6 hours. Administering ampicillin every 6 hours at 200mg/kg could potentially lead to overdose for the neonate. It is important to clarify this dosage with the health care provider before administering the medication to ensure the safety of the newborn.

Correct Answer: A

Rationale: In the context of a newborn with a temperature of 35.5°C (95.9°F), the priority nursing action is to place the newborn under a radiant warmer (Option A). This is because newborns have limited ability to regulate their body temperature, and hypothermia can lead to serious complications such as respiratory distress, hypoglycemia, and metabolic acidosis. Placing the newborn under a radiant warmer helps to prevent further heat loss and stabilize the infant's temperature. Administering warm IV fluids (Option B) is not the priority in this situation as direct warming of the newborn is more effective in addressing hypothermia. Swaddling the newborn in warm blankets (Option C) may provide some insulation but may not be sufficient to rapidly raise the infant's temperature. Providing glucose supplementation (Option D) is not indicated as the primary concern in this scenario is to address the hypothermia promptly to prevent further complications. In an educational context, understanding the significance of maintaining newborn thermoregulation is crucial for nursing practice in maternal newborn care. Nurses need to be able to recognize signs of hypothermia in newborns and take prompt action to address it, as even mild hypothermia can have detrimental effects on a newborn's health and wellbeing. Placement under a radiant warmer is a standard intervention to stabilize the newborn's temperature quickly and prevent complications associated with hypothermia.

Correct Answer: B

Rationale: In the context of a mother receiving magnesium sulfate therapy, the primary nursing concern is to monitor deep tendon reflexes hourly. This is crucial because magnesium sulfate is a central nervous system depressant used to prevent seizures in pre-eclampsia and eclampsia. Monitoring deep tendon reflexes helps assess the level of neuromuscular blockade caused by magnesium sulfate. Decreased or absent reflexes indicate drug toxicity, which can progress to respiratory depression, cardiac arrest, and maternal death if not promptly addressed. Monitoring blood pressure every 4 hours (Option A) is important in pre-eclampsia but is not the primary concern when a mother is on magnesium sulfate therapy. Assessing respiratory rate and effort (Option C) is essential but not the primary concern compared to monitoring deep tendon reflexes. Preparing for delivery if signs of toxicity appear (Option D) is important but is an action taken after recognizing toxicity, not the primary concern for ongoing monitoring. Educationally, understanding the rationale behind closely monitoring deep tendon reflexes while a mother is on magnesium sulfate therapy reinforces the importance of pharmacological knowledge in maternal care. It emphasizes the critical role nurses play in assessing and managing potential medication side effects to ensure optimal maternal and fetal outcomes.

Correct Answer: C

Rationale: Vaginal spotting or light bleeding is one of the early signs of an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of vaginal spotting or light bleeding may indicate the implantation of the fertilized egg in a location other than the uterus, leading to the suspicion of an ectopic pregnancy. It is essential for the nurse to recognize this early sign and promptly assess the client for further evaluation and intervention to prevent complications such as rupture and severe bleeding that can be life-threatening.

Correct Answer: A

Rationale: Terbutaline is used for the management of preterm labor, not postpartum hemorrhage (PPH). The medication that are contraindicated for the management of PPH include Cytotec, Hemabate, Pitocin, and Methergine. Terbutaline is not typically used for PPH as it is mainly utilized to delay preterm labor contractions and prevent premature birth.