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Assessment findings of a 4-hour-old newborn include murmur, irregular respiratory rate at 64 breaths/min, heart rate of 150 beats/min with soft murmur, jitteriness, hypotonic, and weak cry. Based on these findings, which action should the nurse implement?
- A. Obtain a heel stick blood glucose level.
- B. Document the findings in the record.
- C. Swaddle the infant in a warm blanket.
- D. Place a pulse oximeter on the heel.
Correct Answer: A
Rationale: Jitteriness, hypotonia, and weak cry suggest hypoglycemia; a heel stick glucose test is critical for confirmation and prompt treatment.
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The nurse reports the current assessment findings to the healthcare provider (HCP). Based on the assessment findings, the priority diagnosis suspected is preeclampsia. This diagnosis places the client at risk of which complications?
- A. Seizures.
- B. Stroke.
- C. Organ damage.
- D. Preterm birth.
Correct Answer: A,B,C,D
Rationale: Preeclampsia increases risks of seizures (eclampsia), stroke, organ damage (liver/kidneys), and preterm birth due to placental insufficiency.
A woman who is trying to get pregnant tells the nurse that she was very disappointed several months ago when she was informed that her positive pregnancy test was a false positive. Which method of determining pregnancy provides the greatest degree of accuracy?
- A. Visualization of implantation by vaginal ultrasound.
- B. Maternal blood serum tests positive for alpha-fetoprotein.
- C. Presence of amenorrhea for 2 months.
- D. Reports feeling tired all of the time.
Correct Answer: A
Rationale: Vaginal ultrasound directly visualizes the implanted embryo, providing the highest accuracy compared to biochemical tests or subjective symptoms, which can be misleading.
What instructions should the nurse provide to a new mother regarding postpartum care and monitoring the newborn's health?
- A. You will need to set up an appointment with your obstetrician in 8 weeks.
- B. You will need to abstain from sexual activities untilå½¼æ¤, and until you see your obstetrician.
- C. Contact the pediatrician if the baby is not breastfeeding well or has fewer wet diapers and stools.
- D. The lactation nurse will be coming by to work with you and your baby.
Correct Answer: C
Rationale: Monitoring breastfeeding success and diaper output is critical for detecting newborn health issues like dehydration, unlike incorrect obstetrician visit timing or less comprehensive lactation support.
A client who delivered vaginally 18 hours ago develops a slight fever. The client's delivery record shows spontaneous rupture of membranes (SROM) for 36 hours prior to delivery and labor lasting 24 hours. An epidural was placed during labor, and she experienced a third-degree perineal laceration. The nurse should recognize which information poses the greatest risk for developing postpartum endometritis?
- A. SROM for 36 hours.
- B. Labor lasting for 24 hours.
- C. Third-degree perineal laceration.
- D. Epidural anesthesia.
Correct Answer: A
Rationale: Prolonged SROM significantly increases the risk of postpartum endometritis due to extended exposure to pathogens.
The nurse knows that hydralazine, while magnesium sulfate will help prevent seizures, will help decrease blood pressure thus?
- A. Improving kidney function.
- B. Supporting liver health.
- C. Preventing arrhythmias.
- D. Lowering cholesterol levels.
Correct Answer: A
Rationale: Hydralazine's vasodilation lowers blood pressure, improving renal perfusion and kidney function, critical in preeclampsia management.