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A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?
- A. Substernal retractions
- B. Acrocyanosis
- C. Overlapping suture lines
- D. Head circumference 33 cm (13 in)
Correct Answer: A
Rationale: The correct answer is A: Substernal retractions. Substernal retractions in a newborn may indicate respiratory distress, which requires immediate attention from the provider to prevent further complications. Acrocyanosis (choice B) is a common finding in newborns and is considered normal. Overlapping suture lines (choice C) can be a result of molding during the birth process and typically resolve on their own. A head circumference of 33 cm (13 in) (choice D) falls within the normal range for a newborn and does not require immediate reporting.
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A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus indicates uterine atony, a common cause of postpartum hemorrhage. A full bladder can displace the uterus further, exacerbating the risk of hemorrhage. Emptying the bladder will allow the uterus to contract properly and reduce the risk. Reassessing the client in 2 hours (A) delays immediate intervention. Administering simethicone (B) is for gas relief and not relevant in this situation. Instructing the client to lie on their right side (D) does not address the underlying issue of uterine atony.
A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?
- A. Reassess the client in 2 hr.
- B. Administer simethicone.
- C. Assist the client to empty their bladder.
- D. Instruct the client to lie on their right side.
Correct Answer: C
Rationale: The correct answer is C: Assist the client to empty their bladder. Palpating the uterus above the umbilicus 12 hours postpartum indicates uterine displacement due to a full bladder. A distended bladder can displace the uterus, leading to uterine atony and increased risk of postpartum hemorrhage. By assisting the client to empty their bladder, the nurse can help the uterus return to its proper position, reducing the risk of complications. Reassessing the client in 2 hours (A) does not address the immediate issue of bladder distention. Administering simethicone (B) is indicated for gas relief and not related to the palpated uterus. Instructing the client to lie on their right side (D) may be uncomfortable and does not address the underlying bladder distention.
A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?
- A. Restrict hourly fluid intake to 150 mL/hr.
- B. Have calcium gluconate readily available.
- C. Assess deep tendon reflexes every 6 hr.
- D. Monitor intake and output every 4 hr.
Correct Answer: B
Rationale: The correct answer is B: Have calcium gluconate readily available. Magnesium sulfate can lead to magnesium toxicity, causing muscle weakness, respiratory depression, and cardiac arrest. Calcium gluconate is the antidote for magnesium sulfate toxicity, as it antagonizes the effects of magnesium on skeletal muscle and cardiac function. It is essential to have calcium gluconate readily available in case of magnesium toxicity.
Incorrect Choices:
A: Restricting hourly fluid intake is not necessary for a client with preeclampsia receiving magnesium sulfate IV.
C: Assessing deep tendon reflexes every 6 hours is not the most critical action to take to prevent or manage magnesium toxicity.
D: Monitoring intake and output every 4 hours is important for overall client assessment but is not directly related to managing magnesium toxicity in this scenario.
A nurse is performing an initial assessment of a newborn who was delivered with a nuchal cord. Which of the following clinical findings should the nurse expect?
- A. Telangiectatic nevi
- B. Facial petechiae
- C. Periauricular papillomas
- D. Erythema toxicum
Correct Answer: B
Rationale: The correct answer is B: Facial petechiae. A nuchal cord occurs when the umbilical cord is wrapped around the baby's neck at birth. This can cause pressure on the baby's blood vessels, leading to tiny red or purple spots on the face called petechiae. This finding indicates possible trauma during delivery. Telangiectatic nevi (choice A) are not typically associated with nuchal cords. Periauricular papillomas (choice C) are benign growths near the ear and are unrelated to nuchal cords. Erythema toxicum (choice D) is a common newborn rash that is not specifically linked to nuchal cords.
A nurse is caring for a client who is 1 day postpartum and breastfeeding her newborn. The client reports sore nipples. Which of the following actions should the nurse take?
- A. Instruct the client to wait 4 hr between daytime feedings.
- B. Assess the newborn's latch while breastfeeding.
- C. Have the client limit the length of breastfeeding to 5 min per breast.
- D. Offer supplemental formula between the newborn's feedings.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Assessing the newborn's latch while breastfeeding is crucial in addressing sore nipples. A poor latch can lead to nipple pain. By ensuring proper latch, the nurse can help alleviate the client's discomfort. Other actions are incorrect:
A: Waiting 4 hr between feedings can lead to engorgement and worsen nipple soreness.
C: Limiting breastfeeding time to 5 min can hinder milk supply and not address the root cause.
D: Offering supplemental formula can interfere with establishing breastfeeding and may not address the latch issue.