A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Which of the following actions should the nurse the nurse takes? (Click on the "Exhibit" Button for additional information about the newborn. There are three tabs that contain separate categories of date.)

Correct Answer: D

Rationale: Since the newborn was born at 35 weeks of gestation, with a birth weight of 2.3 kg and exhibiting clinical signs of hypoglycemia, one of the key priorities in caring for this newborn is monitoring for complications related to prematurity. Measuring the abdominal circumference at the level of the newborn's umbilicus every 2 hours is important in assessing for signs of abdominal distention, which could indicate necrotizing enterocolitis (NEC), a serious condition commonly seen in premature infants. Early detection through frequent abdominal circumference measurements can aid in timely intervention and management to prevent significant complications. Administering nitric oxide inhalation therapy, inserting an orogastric decompression tube with low wall suction, and providing iron-rich formula containing vitamin B12 every 2 hours are not indicated based on the information provided in the exhibit.

Correct Answer: D

Rationale: At the 24-week prenatal appointment, it is essential to conduct the blood type and Rh test for the pregnant client. Determining the mother's blood type (A, B, AB, O) and Rh factor (positive or negative) is crucial as it helps identify if the mother is Rh-negative and at risk for Rh incompatibility with her baby. This information is vital for appropriate management to prevent potential complications such as hemolytic disease of the newborn. Conducting the blood type and Rh test at this stage allows healthcare providers to take necessary precautions to protect both the mother and the fetus.

Correct Answer: C

Rationale: Cephalohematoma is a collection of blood between the skull and its periosteum that occurs due to rupture of blood vessels during birth trauma. It is typically found on one side of the head and does not cross the suture line. In contrast, caput succedaneum is a diffuse swelling that occurs on the newborn's scalp and can cross the suture lines. Nevus flammeus is a vascular birthmark that appears as a pink or red patch on the skin, unrelated to trauma. Erythema toxicum is a benign rash that appears as red spots or patches with a white or yellow papule in the center, also unrelated to trauma.

Correct Answer: D

Rationale: When a baby is born with an unexpected defect, it is crucial for the nursing staff to explain the defect to the parents and show the baby to them as soon as possible. This approach allows for open communication, transparency, and the opportunity for the parents to start processing the situation emotionally. By involving the parents and keeping them informed, trust and understanding can be established between the healthcare providers and the family, ultimately fostering a supportive environment for everyone involved in the care of the baby. It is essential to approach the situation with empathy and sensitivity while providing the necessary information to the parents.

Correct Answer: A

Rationale: The statement "Condoms come in different sizes; it is important I get the right size to ensure proper protection" indicates that the patient understands the teaching about condom use. This statement shows an understanding of the importance of choosing the appropriate condom size for effective protection during sexual encounters. It reflects the patient's grasp of the information provided by the nurse regarding condom use, which is crucial in promoting safe practices to prevent sexually transmitted infections and unintended pregnancies.