Nokea
Four newborns are in the neonatal nursery, none of whom is crying or in distress. Which of the babies should the nurse report to the neonatologist?
- A. 16-hour-old baby who has yet to pass meconium.
- B. 16-hour-old baby whose blood glucose is 50 mg/dL.
- C. 2-day-old baby who is breathing irregularly at 70 breaths per minute.
- D. 2-day-old baby who is excreting a milky discharge from both nipples.
Correct Answer: C
Rationale: Irregular breathing at 70 breaths per minute could indicate respiratory distress and requires further evaluation.
You may also like to solve these questions
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included?
- A. Clean the eyes from outer canthus to inner canthus.
- B. Cleanse the ear canals with a cotton swab.
- C. Assemble all supplies before beginning the bath.
- D. Check the temperature of the bath water with the fingertips.
Correct Answer: C
Rationale: Preparing supplies ensures efficiency and safety during bathing.
A client, who had no prenatal care, delivers a 10-lb 10-oz baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum checkup?
- A. Glucose tolerance test.
- B. Indirect Coombs' test.
- C. Blood urea nitrogen (BUN).
- D. Complete blood count (CBC).
Correct Answer: A
Rationale: Glucose testing is indicated for gestational diabetes.
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: The correct answer is B: full bladder. A full bladder can cause the fundus to be boggy, elevated, and deviated to one side due to impeding the uterus from contracting properly. This can lead to postpartum hemorrhage. Uterine rupture (A) would present with severe abdominal pain and signs of shock. Perineal laceration (C) would not cause these fundus changes. Hematoma (D) would present with localized swelling and pain, not fundal changes.
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
- A. Fever.
- B. Flank pain.
- C. Dark-colored urine.
- D. Swelling at the injection site.
Correct Answer: D
Rationale: Localized swelling and dark urine may occur.
A client just delivered the placenta pictured below. For which of the following complications should the nurse carefully observe the woman?
- A. Endometrial ischemia.
- B. Postpartum hemorrhage.
- C. Prolapsed uterus.
- D. Vaginal hematoma.
Correct Answer: B
Rationale: Abnormal placentas increase hemorrhage risk.