A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

"This is meconium stool and is normal for a newborn."

"You probably took iron during your pregnancy and that is what causes this type of stool."

“ This is unusual, and I need to report this to your pediatrician."

I'll take a sample and check it for possible bleeding"

Answer and Explanation

The Correct Answer is A

A. "This is meconium stool and is normal for a newborn." is the correct and most appropriate response. Meconium is the newborn’s first stool, typically passed within the first 24 to 48 hours of life. It is black, tarry, and sticky in appearance and consists of materials the baby ingested while in the womb, such as amniotic fluid, mucus, and cells. It is completely normal and expected.

B. "You probably took iron during your pregnancy and that is what causes this type of stool." is incorrect. While iron supplements can darken adult stools, meconium is unrelated to maternal iron intake and is a normal physiological occurrence in all newborns.

C. “This is unusual, and I need to report this to your pediatrician." is incorrect and would be alarming to the parent unnecessarily. This is a normal finding, not something requiring physician notification.

D. "I'll take a sample and check it for possible bleeding" is also inappropriate unless there are other signs of concern (e.g., blood in stool later on). Meconium is not indicative of bleeding and does not warrant testing under normal circumstances.

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Correct Answer is B

Explanation

A. Difficulty in arousing suggests central nervous system depression, which can be a sign of magnesium toxicity. This is not a therapeutic effect and requires immediate assessment and possible discontinuation of the medication.
B. Deep tendon reflexes 2+ indicates normal neuromuscular function, which is consistent with therapeutic levels of magnesium sulfate. Loss of deep tendon reflexes is often the first sign of magnesium toxicity, so their presence at a normal level is reassuring.
C. Urinary output of 20 mL per hour is below the expected minimum (typically 30 mL/hour) and may suggest impaired renal function, which increases the risk of magnesium accumulation and toxicity.
D. Respiratory rate of 10 breaths/minute is lower than normal and may indicate respiratory depression, a serious sign of magnesium toxicity. A rate below 12 breaths/minute is concerning and not consistent with therapeutic dosing.

A. Request the client to empty her bladder B. Follow PRN order to insert a straight urinary catheterization C. Start an IV and add 20 units Pitocin D. Massage fundus until it descends below the level on umbilicus.

Correct Answer is A

Explanation

A. Request the client to empty her bladder is the correct action. A fundus that is firm but deviated to the left and higher than expected (U+1) suggests that the bladder is full. A full bladder can displace the uterus, causing it to become misaligned and elevated. Asking the client to empty her bladder is often the first step to address this situation before proceeding with further assessment or intervention.

B. Follow PRN order to insert a straight urinary catheterization might be appropriate if the client is unable to empty her bladder voluntarily, but it is typically a last resort. Before resorting to catheterization, encourage the client to try to void first.

C. Start an IV and add 20 units Pitocin would be indicated if there were signs of uterine atony or hemorrhage. However, in this case, the issue seems related to bladder distention rather than uterine atony, so starting Pitocin is not the appropriate immediate response.

D. Massage fundus until it descends below the level of the umbilicus would be done if the fundus were boggy or soft, indicating uterine atony. However, in this case, the fundus is described as firm, so massaging is not necessary. The priority is addressing the bladder distention.

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A new mother is changing the diaper of her 12-hour-old newborn and asks why the stool is black and sticky. Which response by the nurse would be most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is diagnosed with gestational hypertension and is receiving magnesium sulfate. The nurse determines that the medication is at a therapeutic level based on which finding?

Correct Answer is B

Explanation

During a routine postpartum assessment following a normal vaginal delivery, the nurse notes the fundus is firm, but the level has changed from U-1 to U+1 and deviated to the left. Which action would be appropriate before continuing the assessment?

Correct Answer is A

Explanation

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