A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?

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

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

A newborn who is 12 hours post-delivery and has a temperature of 37.5°C (99.5°F)

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

Answer and Explanation

The Correct Answer is D

Choice A rationale
A newborn typically begins to void within 24 hours after birth, so not voiding within this time frame is not immediately concerning.
Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns, especially within the first few hours after birth. It is a normal finding and does not require immediate intervention.
Choice C rationale
A temperature of 37.5°C (99.5°F) is within the normal range for a newborn. Therefore, this does not require immediate attention.
Choice D rationale
Newborns typically pass meconium, the first stool, within 24 to 48 hours after birth. If a newborn has not passed meconium within 24 hours, it could indicate a problem such as meconium ileus, a complication of cystic fibrosis, or other conditions that might obstruct the bowel. This situation requires immediate attention and intervention.

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Correct Answer is C

Explanation

The correct answer is choiceC. Respiratory rate.

Choice A rationale:

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus.However, when administering magnesium sulfate, the primary concern is the mother’s respiratory status due to the risk of respiratory depression, which can be a side effect of the medication.

Choice B rationale:

While bowel sounds are an important part of a comprehensive assessment, they are not the primary concern when administering magnesium sulfate.Magnesium sulfate primarily affects the neuromuscular and respiratory systems.

Choice C rationale:

Respiratory rate is the primary nursing assessment for a client receiving magnesium sulfate IV.Magnesium sulfate can cause respiratory depression, so it is essential to monitor the client’s respiratory status closely to detect any signs of respiratory compromise early.

Choice D rationale:

Monitoring temperature is important in any clinical setting, but it is not the primary concern when administering magnesium sulfate.The primary focus should be on the respiratory rate due to the potential for respiratory depression.

A. It prevents the formation of Rh antibodies in mothers who are Rh negative. B. It destroys Rh antibodies in mothers who are Rh negative. C. It prevents the formation of Rh antibodies in newborns who are Rh positive. D. It destroys Rh antibodies in newborns who are Rh positive.

Correct Answer is A

Explanation

Choice A rationale
Rh(D) immunoglobulin prevents the formation of Rh antibodies in mothers who are Rh negative. If an Rh-negative mother is exposed to Rh-positive blood, as can happen during pregnancy or childbirth, her immune system may respond by making antibodies against the Rh antigen. This can cause problems in future pregnancies if the baby is Rh positive. Rh(D) immunoglobulin works by preventing the mother’s immune system from recognizing the Rh antigen, thus preventing the formation of antibodies.
Choice B rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in mothers who are Rh negative. Once antibodies have formed, they cannot be destroyed by Rh(D) immunoglobulin.
Choice C rationale
Rh(D) immunoglobulin does not prevent the formation of Rh antibodies in newborns who are Rh positive. The purpose of Rh(D) immunoglobulin is to prevent the mother from forming Rh antibodies.
Choice D rationale
Rh(D) immunoglobulin does not destroy Rh antibodies in newborns who are Rh positive. The purpose of Rh(D) immunoglobulin is to prevent the mother from forming Rh antibodies.

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A nurse in the newborn unit is caring for several infants. Which of the following situations requires the nurse's immediate attention and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer magnesium sulfate IV to a client who is in labor. Which of the following is the primary nursing assessment for this client?

Correct Answer is C

Explanation

A nurse is teaching a client who is postpartum and has a new prescription for Rh(D) immunoglobulin. Which of the following should be included in the teaching?

Correct Answer is A

Explanation

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who experienced a vaginal birth 12 hours ago. The nurse recognizes the client is in the dependent, taking in phase of maternal postpartum adjustment. Which of the following findings should the nurse expect during this phase?

A nurse is educating the mother of a newborn who was born small for gestational age. Which of the following should the nurse mention as a potential cause of this condition?

A nurse is preparing to administer vitamin K. Which of the following muscles should the nurse consider for the injection?

A nurse is assessing a newborn who has Trisomy 21 (Down’s Syndrome). Which of the following are common characteristics? (Select all that apply.)

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination.Which of the following explanations of the primary reason should the nurse provide?

A nurse in the newborn unit is caring for several infants.
Which of the following situations requires the nurse's immediate attention and intervention?