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A nurse is observing an adolescent client who is offering her newborn a bottle while he is lying in the bassinet. When the nurse offers to pick the newborn up and place him in the client's arms, the mother states, 'No, the baby is too tired to be held.' Which of the following actions should the nurse take?
- A. Offer to take the newborn to the nursery to finish his feeding
- B. Insist that the mother pick up the newborn to feed him
- C. Demonstrate how to hold the newborn and allow the client to practice
- D. Persuade the client to breastfeed the newborn to promote bonding
Correct Answer: C
Rationale: Demonstrating safe holding respects the client's concerns while promoting bonding, unlike nursery removal, insistence, or pushing breastfeeding.
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A nurse in a newborn nursery is receiving a change-of-shift report for four newborns. Which of the following newborns should the nurse assess first?
- A. A newborn who has a short frenulum and is having difficulty breastfeeding
- B. A newborn who is 24 hr old and has not had a meconium stool
- C. A newborn who is 10 hr old and has blood-tinged discharge in her diaper
- D. A newborn who is 10 hr old and has new onset tachypnea
Correct Answer: D
Rationale: New onset tachypnea signals potential respiratory distress, requiring urgent assessment, unlike breastfeeding issues, delayed stool, or normal blood-tinged discharge.
A nurse is reviewing the electronic medical record of a postpartum client. The nurse should identify that which of the following factors places the client at risk for an infection?
- A. Midline episiotomy
- B. Meconium-stained fluid
- C. Gestational hypertension
- D. Placenta previa
Correct Answer: B
Rationale: Meconium-stained fluid increases maternal infection risk if it enters the bloodstream, unlike episiotomy (managed risk), hypertension, or previa (other complications).
A nurse manager on the labor and delivery unit is teaching a group of newly licensed nurses about maternal cytomegalovirus. Which of the following information should the nurse manager include in the teaching?
- A. Transmission can occur via the saliva and urine of the newborn
- B. This infection requires that airborne precautions be initiated for the newborn
- C. Mothers will receive prophylactic treatment with acyclovir prior to delivery
- D. Lesions are visible on the mother's genitalia
Correct Answer: A
Rationale: CMV transmission occurs through newborn saliva and urine, unlike requiring airborne precautions, acyclovir (herpes treatment), or visible genital lesions (not typical).
A nurse is providing teaching to a client who is primigravid and is scheduled to have an abdominal ultrasound. Which of the following statements by the client indicates an understanding of the teaching?
- A. I won't apply perfumed lotion to my abdomen before the test.
- B. I can't have anything to eat after midnight.
- C. I need to take a stool softener the night before the test.
- D. I will drink water before the test until my bladder feels full.
Correct Answer: D
Rationale: A full bladder enhances ultrasound visibility by displacing intestines, unlike avoiding lotion, fasting, or stool softeners, which are not required.
A nurse is assessing a client who is at 32 weeks of gestation and is receiving magnesium sulphate via continuous IV infusion. Which of the following findings should the nurse report to the provider?
- A. Decrease in frequency of contractions
- B. BP 150/100 mm Hg
- C. Absent deep tendon reflexes
- D. Urinary output 35 mL/hr
Correct Answer: C
Rationale: Absent deep tendon reflexes indicate magnesium toxicity, a serious complication requiring immediate reporting to prevent further harm, unlike reduced contractions (desired effect), elevated BP (monitor but less urgent), or low-normal urine output.