What is the primary nursing action for a newborn experiencing signs of hypoglycemia?

Correct Answer: B

Rationale: In the context of a newborn experiencing signs of hypoglycemia, the primary nursing action should be to feed the newborn breastmilk or formula (Option B). This is the correct answer because providing nutrition, specifically glucose, is essential to raise the blood sugar levels promptly in a hypoglycemic newborn. Breastmilk or formula contains the necessary nutrients, including glucose, to address the hypoglycemic state efficiently. Option A, administering glucose water via a bottle, is incorrect as it may not provide adequate nutrition and could lead to improper dosing of glucose, potentially causing further complications. Option C, monitoring glucose levels and reassessing in 30 minutes, is not the primary action because immediate intervention is necessary to prevent complications associated with hypoglycemia in newborns. Option D, starting an IV glucose drip, is a more invasive intervention that should be considered if the newborn's condition does not improve with oral feeding. However, initiating IV therapy is not the primary action when managing hypoglycemia in newborns unless absolutely necessary. In an educational context, it is crucial for nurses to understand the immediate management of hypoglycemia in newborns to prevent long-term consequences. Providing timely and appropriate nutrition is a fundamental nursing intervention in addressing hypoglycemia in newborns and promoting their well-being.

Correct Answer: C

Rationale: This statement indicates a correct understanding of perineal care after a midline episiotomy. After vaginal birth, it is important to avoid wiping the perineal area to prevent irritation and infection. Instead, gently patting the area dry is recommended to promote healing and prevent discomfort. This approach helps to minimize trauma to the sensitive tissues of the perineum and reduces the risk of introducing bacteria from wiping.

Correct Answer: A

Rationale: A concealed hemorrhage in abruptio placentae, also known as a concealed retroplacental hematoma, can cause rapid, significant bleeding behind the placenta with limited visible external bleeding. This internal bleeding can lead to significant blood loss and can cause the uterus to become tense and firm, resulting in a hard board-like abdomen upon palpation. This clinical sign is a key indicator of a concealed hemorrhage in abruptio placentae and should prompt immediate medical attention to prevent maternal and fetal complications. The other choices, such as decreased fundal height, bradycardia, and decreased abdominal pain, are not typically associated with a concealed hemorrhage in abruptio placentae.

Correct Answer: A

Rationale: When a patient receives an epidural anesthesia during the first stage of labor, it can lead to temporary bladder dysfunction. The epidural can affect the patient's ability to feel the sensation of a full bladder and may impair the ability to voluntarily urinate. If the epidural is discontinued immediately after delivery during the fourth stage of labor, the patient may be at an increased risk of bladder distention due to the residual effects of the epidural. Therefore, monitoring for bladder distention and ensuring adequate bladder emptying is important to prevent complications.

Correct Answer: A

Rationale: The correct first action when a delivering patient's water breaks is to check the fetal heart tone. This is important to assess the well-being of the baby and ensure there are no signs of distress. Once the fetal heart tone is confirmed, the nurse can proceed with notifying the physician, changing bed linen, and encouraging the mother to go for a walk as needed. But the priority should always be to assess the fetal well-being in such a situation.