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 A

Explanation

Choice A rationale
A displaced fundus from the midline in a postpartum client can indicate a full bladder, which can interfere with uterine contraction and lead to excessive bleeding. This is a serious

condition that requires immediate attention to prevent further complications such as postpartum hemorrhage.
Choice B rationale
A fundal height below the umbilicus is a normal finding in a postpartum client. The uterus normally decreases in size after delivery, and the fundus is typically located at or below the level of the umbilicus within 24 hours postpartum.
Choice C rationale
Increased urine output is a normal physiological response after delivery. During pregnancy, there is an increase in blood volume that leads to increased fluid in the body. After delivery, the body eliminates this extra fluid through increased urine output.
Choice D rationale
A decreased urge to void can be a normal finding in the immediate postpartum period due to decreased bladder sensitivity from the trauma of childbirth or epidural anesthesia. However, it’s important for the nurse to monitor this because urinary retention can lead to bladder distention and uterine atony, increasing the risk of postpartum hemorrhage.

A. Expulsion of a blood-tinged mucous plug B. Pressure on the perineum causing the client to bear down C. Continuous contraction lasting 2 min D. Expulsion of clear fluid from the vagina

Correct Answer is C

Explanation

Continuous contractions lasting 2 minutes could indicate uterine tetany, which could lead to uterine rupture, a life-threatening situation that requires immediate medical attention.

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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

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Correct Answer is C

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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?