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Newborn 1 hour after birth, axillary temperature 95.8°F, apical pulse 114 bpm, respiratory rate 60 breaths/minute
When assessing a newborn 1 hour after birth, the nurse measures an axillary temperature of 95.8° F (35.4° C), an apical pulse of 114 beats per minute, and a respiratory rate of 60 breaths per minute. The nurse would identify which area as the priority?
- A. Hypothermia.
- B. Deficient fluid volume.
- C. Impaired gas exchange.
- D. Risk for infection.
Correct Answer: A
Rationale: The low temperature (95.8°F) indicates hypothermia, a priority due to risks of hypoglycemia, acidosis, and impaired oxygen delivery.
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Primigravida client in second stage of labor, moaning and screaming, husband requests pain medication
A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?
- A. Assist the client with breathing and imagery techniques in an attempt to calm her down.
- B. Ask the client to describe the intensity of her pain on a scale of 0 to 10.
- C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.
- D. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.
Correct Answer: A
Rationale: Assisting with breathing and imagery techniques provides nonpharmacological pain relief and supports the client's coping mechanisms, which is appropriate as vocalizing is a normal way to express pain during labor.
Client considered for amniotomy
The nurse understands which condition is a contraindication for an amniotomy.
- A. Right occiput posterior position.
- B. -2 station.
- C. Cephalic presentation.
- D. Dilation less than 3 cm.
Correct Answer: D
Rationale: Dilation less than 3 cm is a contraindication for amniotomy due to increased risks of infection and cord compression.
During vaginal delivery, newborn's head emerges
During a vaginal delivery, the first thing a nurse must ensure when the head comes out is that the midwife or doctor checks that
- A. The cord is still pulsating.
- B. The cord is intact.
- C. No part of the cord is encircling the baby's neck.
- D. The cord is still attached to the placenta.
Correct Answer: C
Rationale: Checking for a nuchal cord (cord around the neck) is critical to prevent compression, which could reduce blood flow and oxygen to the baby.
New mother, postpartum period
Choose the sign or symptom that a new mother should be taught to report:
- A. Occasional uterine cramping when the infant nurses.
- B. Descent of the fundus one fingerbreadth each day.
- C. Reappearance of red lochia after it changes to serous.
- D. Oral temperature that is 37.2 C (99 F) in the morning.
Correct Answer: C
Rationale: Reappearance of red lochia after it becomes serous may indicate uterine atony or retained placental fragments, requiring immediate reporting.
Woman receiving oxytocin (Pitocin) infusion
For which patient should the oxytocin (Pitocin) infusion be discontinued immediately?
- A. A woman in early labor with contractions every 5 minutes lasting 40 seconds each.
- B. A woman in active labor with contractions every 30 minutes lasting 60 seconds each.
- C. A woman in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each.
- D. A woman in transition with contractions every 1.5 minutes lasting 95 seconds each.
Correct Answer: D
Rationale: Contractions every 1.5 minutes lasting 95 seconds in transition indicate hyperstimulation, risking fetal distress, so the infusion should be stopped.