A newborn, who is 4 hours old, presents with the following symptoms: axillary temperature of 96.8° F (35.8° C), heart rate of 150 beats/minute with a soft murmur, irregular respiratory rate at 64 breaths/minute, jitteriness, hypotonicity, and a weak cry.
What should the nurse do based on these findings?

Swaddle the infant in a warm blanket.

Document the findings in the record.

Place a pulse oximeter on the infant’s heel.

Obtain a heel stick blood glucose level.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While swaddling the infant in a warm blanket can help maintain body temperature, it does not address the underlying issue causing the symptoms.

Choice B rationale

Documenting the findings in the record is important, but it is not the immediate action that should be taken. The newborn’s symptoms suggest a possible health issue that needs immediate attention.

Choice C rationale

Placing a pulse oximeter on the infant’s heel can provide information about the newborn’s oxygen saturation, but it does not address the immediate concern of the symptoms presented.

Choice D rationale

Obtaining a heel stick blood glucose level is the correct action. The symptoms presented by the newborn such as jitteriness, hypotonicity, and a weak cry can be signs of hypoglycemia, a condition that can occur in newborns.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Reviewing the pattern of the fetal heart rate is important but not the immediate first step when a client in active labor needs to use the restroom. The nurse should first assess the progress of labor.

Choice B rationale: Checking the client's bladder is necessary, especially if the bladder is full, as it can affect labor progress. However, the priority is to assess the cervix first to ensure the client is not in an advanced stage of labor before addressing bladder concerns.

Choice C rationale: Determining the dilation of the cervix is crucial. The need to use the restroom may indicate increased pressure from the presenting part of the fetus, suggesting rapid labor progression. This assessment will help determine if it is safe for the client to ambulate to the restroom or if other immediate actions are needed.

Choice D rationale: Testing the pH of the vaginal fluid can be part of assessing for the presence of amniotic fluid, but it is not the first step when a client in active labor expresses the need to use the restroom. Cervical assessment takes priority in this situation.

A. Remind her to push three times with each contraction. B. Assessing the strength of uterine contractions. C. Re-evaluate the need for medication. D. Assisting her to maintain control.

Correct Answer is D

Explanation

Choice A rationale

While pushing is a part of labor, reminding the woman to push three times with each contraction is not the primary focus of nursing care during the transitional phase of labor.

Choice B rationale

Assessing the strength of uterine contractions is important, but it is not the primary focus during the transitional phase of labor.

Choice C rationale

Re-evaluating the need for medication is not the primary focus during the transitional phase of labor for a client who anticipates an unmedicated delivery.

Choice D rationale

Assisting the woman to maintain control is the primary focus of nursing care during the transitional phase of labor. This includes providing supportive care and encouragement in dealing with transitional contractions.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who has been admitted in active labor. The cervix is dilated to 3 cm, 50% effaced, and the presenting part is at 0 station. An hour later, the client informs the nurse that she needs to use the restroom. What should be the nurse’s first course of action?

Correct Answer is C

Explanation

What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery?

Correct Answer is D

Explanation

A neonate, who is one day old, develops a cephalhematoma.Which common complication should the nurse assess this neonate for?

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A client at 32 weeks gestation visits the women’s health clinic and reports feeling nauseous and vomiting. Upon examination, the nurse notes that the client’s blood pressure is elevated.What should the nurse do next?

A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time. I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

A multiparous client with active herpes lesions has been admitted to the unit due to spontaneous rupture of membranes.What action should the nurse take?