What is the best nursing action for a newborn experiencing hypothermia?

Correct Answer: A

Rationale: The correct answer is A: Place the newborn in skin-to-skin contact with the mother. This is the best nursing action for a newborn experiencing hypothermia because it provides immediate and effective warmth transfer from the mother to the baby. Skin-to-skin contact helps regulate the newborn's body temperature, promotes bonding, and enhances breastfeeding initiation. Choice B is incorrect because while providing a warm blanket is important, skin-to-skin contact with the mother is more effective in quickly raising the newborn's temperature. Choice C is incorrect because administering IV fluids is not the first-line treatment for hypothermia in newborns. Choice D is incorrect because monitoring glucose levels for hypoglycemia is important but addressing the hypothermia should take precedence.

Correct Answer: B

Rationale: The correct answer is B: Risk for injury. This is because families with special needs in childbearing may face unique challenges leading to potential risks of injury, such as physical limitations or difficulties in providing adequate care. Option A is incorrect as spiritual distress is not directly related to physical safety. Option C is incorrect as enhanced nutrition readiness does not directly address safety concerns. Option D is incorrect as ineffective breathing pattern is a specific health issue not necessarily related to the family's safety. Therefore, B is the most appropriate nursing diagnosis for addressing safety concerns in the childbearing family with special needs.

Correct Answer: B

Rationale: The correct answer is B: Cabbage juice. Cabbage juice contains phytoestrogens that help stimulate blood flow to the breast glands and promote milk production. It is used traditionally to increase milk supply in lactating women. Milk thistle (A) is more commonly used for liver health and not specifically for lactation. Lanolin (C) is a topical ointment for sore nipples, not for milk production. Aloe vera (D) is not recommended for internal use during lactation due to potential laxative effects. In summary, cabbage juice is the best choice as it directly supports milk production and flow in lactating clients.

Correct Answer: B

Rationale: The correct answer is B because complete dilation of the cervix marks the transition from the first to the second stage of labor. This indicates that the client is ready to start pushing the baby out. Choice A is incorrect as ruptured membranes can occur in any stage of labor. Choice C is incorrect as clear vaginal fluid expulsion is not a specific indicator of the second stage. Choice D is incorrect as the urge to push can be experienced in the first stage as well.

Correct Answer: C

Rationale: The correct answer, C, states that excess spermicide should be removed from the vagina within 6 hours to reduce vaginal irritation. This is important as leaving excess spermicide can lead to discomfort and irritation. It is a crucial instruction to ensure the user's comfort and safety. Choice A is incorrect as nonoxynol-9 does not necessarily increase efficacy when used with barrier methods. Choice B is incorrect because while using spermicide with condoms can reduce the risk of STIs, the statement does not specifically address the instructions for use. Choice D is incorrect as placing the spermicide close to the vagina's opening does not guarantee maximal effectiveness and is not a critical instruction for safe use.

Correct Answer: C

Rationale: The correct answer is C: Encourage the mother to avoid heavy lifting. After a third-degree perineal tear, it is crucial to prevent strain on the perineum to promote healing and prevent complications like infection or further tearing. Heavy lifting can increase pressure on the perineum, leading to delayed healing. Ice packs (A) may help reduce swelling initially but do not address the underlying issue. Stool softeners (B) can help prevent constipation and straining during bowel movements but do not directly impact perineal tear healing. Perineal exercises (D) are beneficial for strengthening the pelvic floor muscles in general but should be introduced gradually and not immediately postpartum with a severe tear.

Correct Answer: D

Rationale: The correct answer is D because a breathing pattern that is diaphragmatic with sternal retractions indicates respiratory distress in a newborn, which is a critical condition requiring immediate attention. Staying logical, let's assess the other choices: A: Temperature of 97.7 degrees Fahrenheit is within the normal range for a newborn and does not indicate an urgent issue. B: A pale pink, rust-colored stain in the diaper could be due to various factors such as diet and is not an immediate concern. C: A heart rate dropping to 120 beats/min in a newborn is generally within the normal range and does not signify a critical issue.

Correct Answer: C

Rationale: The correct answer is C: Placing the newborn on mother's chest and abdomen. This promotes parental attachment through skin-to-skin contact, facilitating bonding and emotional connection. It also helps regulate the baby's temperature and encourage breastfeeding. Placing the infant under the radiant warmer (A) may disrupt immediate bonding. Allowing the mother to rest (B) is important, but promoting attachment should be prioritized. Taking the newborn to the nursery (D) can delay the crucial bonding process.

Correct Answer: B

Rationale: Rationale: Choice B is correct because a newborn should have at least 6-8 wet diapers in a 24-hour period, indicating adequate hydration and effective breastfeeding. This frequency of wet diapers is a sign of adequate milk intake and hydration for the baby, which is crucial for their growth and development. Choices A, C, and D are incorrect because feeling a tugging sensation, dark and concentrated urine, and firm breasts are not indicators of effective breathing or breastfeeding in a newborn.