A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Transient circumoral cyanosis

Single palmar creases

Rust-stained urine

Subconjunctival hemorrhage

Answer and Explanation

The Correct Answer is B

A. Transient circumoral cyanosis: This is a common finding in newborns and typically resolves without treatment.

B. The nurse should report the finding of "Single palmar creases" to the provider. Single palmar creases, also known as a single transverse palmar crease or simian crease, are associated with certain genetic syndromes like Down syndrome. It can be a significant clinical finding that warrants further evaluation and potential genetic testing to rule out any underlying conditions.

C. Rust-stained urine: This can occur due to the breakdown of red blood cells in the newborn's body during the first few days of life. It's usually benign and resolves on its own.

D. Subconjunctival hemorrhage: This is a common finding caused by pressure during childbirth and is typically benign, resolving without intervention.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "Moderate variability of the fetal heart rate" is a reassuring sign, indicating that the fetus is tolerating labor well. It does not warrant discontinuing oxytocin.

B. "Nonrepetitive early decelerations" are also a reassuring sign and are typically not an indication to discontinue oxytocin. Early decelerations are typically benign and related to head compression during contractions.

C. "Six contractions in 10 min" may be within the acceptable range for uterine activity during labor. However, it's important to assess the duration and intensity of these contractions as well.

D. "Contractions last 60 seconds" on their own may not be an indication to discontinue oxytocin. The nurse should also assess the frequency and intensity of contractions to determine if they are causing uterine hyperstimulation. Uterine Hyperstimulation Occurs: Uterine hyperstimulation is defined by an excessive frequency, duration, or intensity of contractions. Generally, contractions that occur more frequently than 5 contractions in 10 minutes (one every 2 minutes) or contractions that last longer than 60-90 seconds can be concerning.

A. Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus. B. Ask the client to lie on her back and with her knees flexed. C. Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis. D. Observe the client's perineum for the passage of clots and the amount of bleeding.

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

Explanation

Performing fundal massage for a postpartum client with uterine atony should be done in the following order:
Ask the client to lie on her back and with her knees flexed.

Placing the client in the supine position with knees flexed helps relax the abdominal muscles and facilitates access to the uterus.

Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.

This step involves proper hand placement to locate and assess the position of the uterus.

Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.

After proper hand placement, you can start the fundal massage with a rotating motion using slight downward pressure. This helps stimulate uterine contractions and control bleeding.

Observe the client's perineum for the passage of clots and the amount of bleeding.

While massaging the uterus, it's essential to monitor the client's perineum for any signs of excessive bleeding or clot passage.

So, the correct order is: Ask the client to lie on her back and with her knees flexed > Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis > Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus > Observe the client's perineum for the passage of clots and the amount of bleeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving oxytocin to induce labor. The nurse should discontinue the oxytocin if which of the following occurs?

Correct Answer is D

Explanation

A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

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

Explanation

A nurse is assessing a client who is 6 hr postpartum and has endometritis. Which of the following findings should the nurse expect?

A nurse is caring for a client following a vaginal delivery of a term fetal demise. Which of the following statements should the nurse make?

A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

A nurse is caring for a client who is at 32 weeks of gestation and has gestational diabetes mellitus. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

A nurse is assisting the provider to administer a dinoprostone insert to induce labor for a client. Which of the following actions should the nurse take?

A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

A nurse is caring for a client who is at 30 weeks of gestation. The nurse should plan to Immunize the client with which of the following vaccines? (Select all that apply.)