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Newborn 1 hour after birth
The nurse completes the initial assessment of a newborn. Which finding would lead the nurse to suspect that the newborn is experiencing difficulty with oxygenation?
- A. Acrocyanosis.
- B. Respiratory rate of 54 breaths/minute.
- C. Nasal flaring.
- D. Abdominal breathing.
Correct Answer: C
Rationale: Nasal flaring indicates difficulty with oxygenation, as it is a compensatory mechanism to increase airflow in respiratory distress.
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Laboring woman
The most appropriate time for the nurse to encourage a laboring woman to push is during
- A. the interval between contractions.
- B. whenever she feels the need.
- C. second-stage of labor.
- D. first-stage of labor.
Correct Answer: C
Rationale: The second stage of labor, when the cervix is fully dilated, is the appropriate time to push, as contractions are strong and effective for delivery.
Newborn born at 37 weeks, 12 hours old, tachypnea, grunting, nasal flaring, substernal retractions, acrocyanosis
Complete the diagram by dragging from the choices below to specify what condition the newborn is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the newborn's progress.
- A. Initiate phototherapy as prescribed.
- B. Obtain a urine drug screen.
- C. Administer Surfactant as prescribed.
- D. Administer 30 mL of oral glucose water.
- E. Provide Oxygen Therapy as needed
- F. Hypoglycemia.
- G. Respiratory distress syndrome.
Correct Answer: B
Rationale: Respiratory distress syndrome is likely due to respiratory symptoms. Administer surfactant and provide oxygen therapy address lung immaturity and oxygenation. Monitor arterial blood gases and oxygen saturation to assess progress.
Woman receiving oxytocin stimulation
One side effect of oxytocin stimulation is hypertonic contractions. This can be detrimental to the fetus because
- A. It produces a prolapsed cord.
- B. It increases maternal renal blood flow.
- C. It decreases maternal blood pressure.
- D. There is a reduction of placental blood flow.
Correct Answer: D
Rationale: Hypertonic contractions reduce placental blood flow by limiting the time for the placenta to refill with blood between contractions, risking fetal hypoxia. Note: The document incorrectly lists 'A' as the correct answer, but the explanation supports 'D' as the correct choice based on standard medical understanding.
Client receiving oxytocin (Pitocin) infusion
The priority nursing care associated with an oxytocin (Pitocin) infusion is:
- A. Measuring urinary output.
- B. Evaluating cervical dilation.
- C. Increasing infusion rate every 30 minutes.
- D. Monitoring uterine response.
Correct Answer: D
Rationale: Monitoring uterine response is critical as oxytocin can cause excessive contractions, risking fetal distress, uterine rupture, or placental abruption.
Client 2 hours postpartum, vaginal birth
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?
- A. Client report of frequent uterine contractions.
- B. Fundus palpable to right of midline.
- C. Less than 2.5 cm of rubra lochia on perineal pad.
- D. Client report of increased thirst.
Correct Answer: B
Rationale: A fundus palpable to the right of midline suggests a distended bladder, which can displace the uterus from its normal position.