A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

normal progression of behavior.

probable hypoglycemia.

physiological abnormality.

inadequate oxygenation.

Answer and Explanation

The Correct Answer is A

A. Newborns typically go through predictable behavioral states after birth. During the first period of reactivity, which lasts about 30–60 minutes after birth, the newborn is awake, alert, and active. This is followed by a period of sleep or decreased activity, which can last 2 to 4 hours. It is normal for the baby to be sleepy and difficult to awaken during this phase, especially around 2 hours of age.

B. Probable hypoglycemia could cause lethargy in a newborn, but it would typically be accompanied by other symptoms such as jitteriness, poor feeding, or abnormal vital signs. In a healthy 2-hour-old baby, sleepiness alone is not enough to suggest hypoglycemia.

C. Physiological abnormality is incorrect. There is no evidence of abnormality in a sleepy 2-hour-old newborn, as this is an expected part of the normal behavioral cycle after birth.

D. Inadequate oxygenation would likely present with signs such as cyanosis, abnormal respiratory rate, or poor perfusion, not just sleepiness.

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Correct Answer is D

Explanation

A. Jaundice is not typically a primary concern in the case of a ruptured ectopic pregnancy. Jaundice is more associated with liver dysfunction, not hemorrhage or the acute events following an ectopic pregnancy rupture.

B. Depression is an emotional response that could occur after a traumatic event like an ectopic pregnancy, but it is not the priority in an acute situation where physical signs of a life-threatening condition like hemorrhage need immediate attention.

C. Edema may be present in a variety of conditions but is not as urgent or immediately life-threatening as hemorrhage in the case of a ruptured ectopic pregnancy.

D. Hemorrhage is the priority concern in a suspected ruptured ectopic pregnancy. A ruptured ectopic pregnancy can lead to significant internal bleeding, which can cause hypovolemic shock and be life-threatening. Immediate attention to monitoring for signs of hemorrhage (such as hypotension, tachycardia, dizziness, and abdominal pain) is crucial to ensure the client's safety.

A. Requests time to talk on the phone B. Hesitate to initiate contact with the newborn C. Allows staff to perform most of the infant's care D. Questions the nurse about frequency of feeding for the newborn

Correct Answer is D

Explanation

A. Requests time to talk on the phone is more reflective of the "taking in" phase, where the mother is focused on herself and her own needs, such as resting and reflecting on the birth experience. This phase typically involves less engagement with the baby and more focus on recovery.

B. Hesitates to initiate contact with the newborn is characteristic of the "taking in" phase as well. During this phase, the mother may still be adjusting and may not yet feel confident in caring for her baby, often focusing more on her own recovery.

C. Allows staff to perform most of the infant's care is also more indicative of the "taking in" phase. During this phase, the mother is still learning and may feel less confident, often relying on others to care for the newborn.

D. Questions the nurse about frequency of feeding for the newborn is a behavior typically seen in the "taking hold" phase. During this phase, the mother becomes more active in caring for the baby, taking responsibility for its care, and showing interest in learning about the baby’s needs (such as feeding). This phase involves a shift toward becoming more independent and engaged in infant care.

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A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

Correct Answer is D

Explanation

Which observed behavior would indicate to the nurse that a post-partum client had progressed to the "taking hold" phase?

Correct Answer is D

Explanation

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