Author Question: A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to ... (Read 130 times)

saliriagwu

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A nurse is assessing a newborn who is about 41/2 hours old. The nurse would expect this newborn to exhibit which of the following? (Select all that apply.)
 
  A) Sleeping
  B) Interest in environmental stimuli
  C) Passage of meconium
  D) Difficulty arousing the newborn
  E) Spontaneous Moro reflexes

Question 2

A pregnant patient is diagnosed with placenta previa. Which action should the nurse implement immediately for this patient?
 
  A) Assess fetal heart sounds with an external monitor.
  B) Help the patient remain ambulatory to reduce bleeding.
  C) Assess uterine contractions by an internal pressure gauge.
  D) Prepare for a vaginal examination to assess the extent of bleeding.



briseldagonzales

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Answer to Question 1

B, C
Feedback:
The newborn is in the second period of reactivity, which begins as the newborn awakens and shows an interest in environmental stimuli. This period lasts 2 to 8 hours in the normal newborn (Boxwell, 2010). Heart and respiratory rates increase. Peristalsis also increases. Thus, it is not uncommon for the newborn to pass meconium or void during this period. In addition, motor activity and muscle tone increase in conjunction with an increase in muscular coordination. Spontaneous Moro reflexes are noted during the first period of reactivity. Sleeping and difficulty arousing the newborn reflect the period of decreased responsiveness.

Answer to Question 2

A
Feedback:
For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine contractions are contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both mother and child. To ensure an adequate blood supply to the patient and fetus, the patient should be placed immediately on bed rest in a side-lying position.



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