When the nurse determines they have a high-risk newborn and birthing person in their care, what can they do to mitigate the situation?

Correct Answer: C

Rationale: The correct answer is C: Refer the couplet to social work for early intervention. This is the best course of action as social work can provide support and resources to address the high-risk situation. Documenting in the chart (A) is important but not sufficient for immediate intervention. Reassuring the parent (B) may be helpful, but it doesn't address the risk factor. Referring to a pediatric provider (D) is important but social work intervention can provide more comprehensive support in this specific situation.

Correct Answer: B

Rationale: In the context of newborn care, administering erythromycin ophthalmic ointment is a standard practice to prevent ophthalmia neonatorum, which is a bacterial infection that can lead to blindness if left untreated. The correct answer, option B, instructs the nurse to cleanse the newborn's eyes from the inner to outer canthus before applying the ointment. This technique is crucial to remove any debris or secretions that may harbor bacteria, ensuring the ointment can effectively reach the eye and provide protection. Option A is incorrect because the timing of administration is typically within the first hour of birth, not necessarily within the first 15 minutes. Option C is incorrect as applying the ointment directly over the cornea can be harmful and cause irritation. Option D is incorrect as flushing the eyes after instillation can potentially wash away the protective ointment before it has a chance to take effect. In an educational context, it is essential for nursing students to understand the rationale behind the correct administration of medications to newborns to ensure optimal outcomes and prevent complications. Emphasizing the correct technique of cleansing the eyes before applying the ointment reinforces the principles of aseptic technique and safe medication administration in neonatal care. This knowledge is crucial for student nurses to provide evidence-based, safe, and effective care to newborns in their practice.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Hypoglycemia. Infants born to diabetic mothers or large-for-gestational-age babies are at risk for hypoglycemia due to their increased insulin production in utero. A newborn with a flushed complexion, tremors, and being chubby is showing signs of hypoglycemia, which can lead to neurologic symptoms like tremors. Option A) Hypocalcemia is less likely in this case as the presentation is more suggestive of hypoglycemia. Birth injury (Option B) would typically present with localized symptoms, not generalized tremors. Seizures (Option D) are a possible consequence of severe hypoglycemia if left untreated. Educationally, understanding the signs and symptoms of common newborn conditions like hypoglycemia is crucial for nurses caring for newborns. Recognizing these early signs can lead to prompt intervention and prevent serious complications. Nurses need to be vigilant in assessing newborns for signs of hypoglycemia, especially in high-risk cases, to provide appropriate care and support.

Correct Answer: C

Rationale: In the context of pharmacology and newborn care, the administration of Vitamin K to newborns is crucial for enhancing the ability of blood to clot. Newborns are born with low levels of Vitamin K, which is essential for the production of clotting factors. Without adequate Vitamin K, newborns are at risk of developing a rare but serious bleeding disorder called Vitamin K deficiency bleeding. By providing Vitamin K at birth, healthcare providers can prevent this potential complication and ensure that the newborn's blood can clot effectively to prevent excessive bleeding. Regarding the incorrect options: A) Vitamin K does not directly reduce bilirubin levels. Bilirubin is a product of the breakdown of red blood cells and is not influenced by Vitamin K. B) Vitamin K does not increase the production of red blood cells. Its primary role is in the clotting cascade. D) Stimulating the formation of surfactant is not a function of Vitamin K. Surfactant is a substance that helps keep the air sacs in the lungs open and is not related to clotting factors. Educationally, understanding the rationale behind giving Vitamin K to newborns is essential for nursing students caring for newborns. It highlights the importance of preventing potential bleeding disorders and ensuring the newborn's health and well-being. By grasping this concept, students can provide safe and effective care to newborns, emphasizing the significance of administering Vitamin K as a standard practice in newborn care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) "My bleeding will remain red for about a month." This statement indicates a misunderstanding of postpartum bleeding. It is essential for the nurse to clarify this misconception because postpartum bleeding typically transitions from bright red to pinkish to yellowish-white over the course of a few weeks, not remaining red for a month. This information is crucial for the woman's understanding of what to expect post-delivery. Option A) "The flow will increase if I am too active" is incorrect because being active can actually help decrease postpartum bleeding by promoting uterine contractions. Option B) "I should expect a lighter flow next week" is incorrect as postpartum bleeding typically decreases gradually over several weeks, not necessarily becoming lighter by the following week. Option D) "I will be able to use a pantiliner in a day or two" is incorrect because postpartum bleeding is usually heavier initially and may require more absorbent pads than a pantiliner in the first few days. Educationally, understanding postpartum bleeding patterns is crucial for nurses caring for postpartum women. Providing accurate information can help new mothers manage their expectations and monitor their postpartum recovery effectively. It also ensures that any abnormal bleeding is identified promptly, promoting overall maternal well-being.