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A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?
- A. A newborn who is 26 hr old and has erythema toxicum on their face
- B. A newborn who is 32 hr old and has not passed a meconium stool
- C. A newborn who is 12 hr old and has pink-tinged urine
- D. A newborn who is 18 hr old and has an axillary temperature of 37.7°C (99.9°F)
Correct Answer: B
Rationale: The correct answer is B because failure to pass meconium within 24-48 hours can indicate a bowel obstruction or other serious issue that needs immediate attention. A: Erythema toxicum is a common benign rash in newborns. C: Pink-tinged urine can be due to uric acid crystals and is normal in newborns. D: An axillary temperature of 37.7°C (99.9°F) is within normal range for a newborn.
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A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?
- A. "The nurse will carry your baby in their arms to the nursery for scheduled procedures."
- B. "We will document the relationship of visitors in your medical record."
- C. "It's okay for your baby to sleep in the bed with you while in the hospital."
- D. "Staff members who take care of your baby will be wearing a photo identification badge."
Correct Answer: D
Rationale: The correct answer is D: "Staff members who take care of your baby will be wearing a photo identification badge." This statement promotes security and safety by ensuring that only authorized personnel are handling the newborn. It helps prevent unauthorized individuals from accessing the baby. The photo identification badge serves as visual confirmation of the staff members' credentials and authority. This measure enhances the client's peace of mind and trust in the healthcare team.
Other choices are incorrect:
A: Carrying the baby to the nursery for procedures may not guarantee security as it could expose the baby to unnecessary risks.
B: Documenting visitor relationships is important but does not directly address the safety and security of the newborn.
C: Sharing a bed with the baby can increase the risk of accidental suffocation or other sleep-related risks.
Overall, choice D is the most direct and effective way to ensure the security and safety of the newborn.
A nurse is caring for a client who delivered by cesarean birth 6 hr ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which of the following actions should the nurse take?
- A. Replace the surgical dressing.
- B. Evaluate urinary output.
- C. Apply an ice pack to the incision site.
- D. Administer 500 mL lactated Ringer’s IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Administer 500 mL lactated Ringer’s IV bolus. This action is necessary to address the ongoing vaginal bleeding after cesarean birth, which may indicate hypovolemia or postpartum hemorrhage. Administering IV fluids helps to restore circulating volume and maintain adequate perfusion to prevent further complications.
Replacing the surgical dressing (A) does not address the underlying issue of vaginal bleeding. Evaluating urinary output (B) is important for assessing renal function but is not the priority in this situation. Applying an ice pack to the incision site (C) is not appropriate for treating postpartum bleeding. Administering a lactated Ringer’s IV bolus (D) is the most urgent intervention to manage the ongoing bleeding and prevent further complications.
The nurse is assessing the client 30 min later. How should the nurse interpret the findings? For each finding, click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
- A. Fundus at level of umbilicus
- B. Cloudy urine
- C. Blood pressure 80/50 mm Hg
- D. Moderate lochia rubra
- E. Thready pulse
- F. Fundus firm to palpation
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Fundus at the level of the umbilicus is an indication of potential improvement as it indicates proper involution of the uterus.
- Cloudy urine is unrelated to the diagnosis and may indicate other issues like urinary tract infection.
- Blood pressure of 80/50 mm Hg is an indication of potential worsening condition as it is hypotensive.
- Moderate lochia rubra is also an indication of potential worsening condition as it may indicate excessive bleeding.
- Thready pulse is unrelated to the diagnosis.
- Fundus firm to palpation is an indication of potential improvement as it indicates proper uterine contraction and involution.
A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?
- A. Administer penicillin G 2.4 million units IM to the client.
- B. Instruct the client to schedule an annual pelvic examination.
- C. Tell the client they will start medication for HIV immediately after delivery.
- D. Report the client’s condition to the local health department.
Correct Answer: D
Rationale: The correct answer is D: Report the client’s condition to the local health department. This is crucial to ensure proper monitoring, contact tracing, and prevention of transmission to others. Reporting the client's HIV status is mandatory for public health purposes. Administering penicillin G (choice A) is not relevant in this scenario. Instructing the client to schedule a pelvic exam (choice B) and starting HIV medication after delivery (choice C) are not immediate actions needed to address the client's HIV status.
A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?
- A. O2 saturation
- B. Temperature
- C. Blood pressure
- D. Urinary output
Correct Answer: B
Rationale: The correct answer is B: Temperature. During an amniotomy, there is an increased risk of infection due to the introduction of bacteria into the uterine cavity. Monitoring the client's temperature is crucial to detect any signs of infection promptly. A sudden spike in temperature could indicate chorioamnionitis, a serious infection that can harm both the mother and the baby. O2 saturation (A), blood pressure (C), and urinary output (D) are important assessments but are not the priority in this situation. Monitoring O2 saturation is essential for fetal well-being but is not directly related to the amniotomy procedure. Blood pressure monitoring is significant for detecting any changes in maternal status, but infection assessment takes precedence in this case. Urinary output is essential for assessing hydration status and kidney function, but infection monitoring is more critical during an amniotomy.