A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

A newborn who is 18 hr post-delivery and has acrocyanosis

A newborn who is 24-hr post-delivery and has not passed meconium

A newborn who is 24 hr post-delivery and has persistent tachycardia with a heart rate of 180 bpm

A newborn who is 24 hr post-delivery and has not voided

Answer and Explanation

The Correct Answer is C

A.   Acrocyanosis is a normal finding in newborns and does not require immediate intervention.
B.   Not passing meconium within the first 24 hours is not uncommon and may be normal.
C. Persistent tachycardia in a newborn, especially with a heart rate of 180 bpm, requires immediate intervention as it may indicate a cardiac or other medical issue.
D.   Not voiding within the first 24 hours may be normal, but it should be monitored.

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Correct Answer is ["A","C","D"]

Explanation

A. Microwaving breast milk decreases vitamin C content.
B. Microwaving does not render the milk tasteless, but it may alter the taste slightly.
C. Microwaving does not heat breast milk evenly, creating hot spots that can burn the baby's mouth.
D. Microwaving can decrease the antiinfective properties of breast milk.
E. Microwaving breast milk does not decrease iron content.

A. Document the findings and continue to monitor the client. B. Encourage the client to empty her bladder. C. Increase the frequency of fundal massage. D. Notify the client’s provider.

Correct Answer is A

Explanation

A. The presence of lochia rubra with small clots in the immediate postpartum period is expected. The firm and midline fundus indicates appropriate uterine contraction. Continued monitoring is appropriate.
B. Encouraging the client to empty her bladder is a valid intervention, but it is not the priority in this situation.
C. Increasing the frequency of fundal massage is unnecessary, as the fundus is already firm.
D. Notifying the provider is not necessary based on the described findings, as they are within the expected range.

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A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns requires immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a new mother the best method to store milk and use it later for feeding. She explains that the breast milk should never be thawed or heated in a microwave oven because of the following reasons. Please select all that apply

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn?

A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.)

A nurse is caring for a client who experienced a vaginal delivery 16 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

A nurse is caring for a client who is postpartum who asks the nurse when her breast milk will "come in." Which of the following responses should the nurse make?

A nurse is assessing a newborn immediately following a scheduled cesarean delivery. Which of the following assessments is the nurse’s priority?

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn’s nose and mouth. Which of the following actions is the nurse’s priority?