A nurse is assisting with the care of a postpartum client who gave birth 3 days ago.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to evaluate the client's progress.

Answer and Explanation

The Correct Answer is []

Endometritis. The client has fever (38.4°C/101.1°F), tachycardia (HR 108/min), uterine tenderness, and foul-smelling lochia, all of which indicate postpartum uterine infection. Prolonged rupture of membranes and cesarean birth increase the risk of endometritis.
Engorgement. The client reports firm and heavy breasts but denies nipple discomfort, making engorgement unlikely as the primary issue.
Deep vein thrombosis. The client has bilateral lower extremity edema but no pain, warmth, or tenderness, which are key signs of DVT.
Urinary tract infection. The client reports frequent voiding without difficulty, with no dysuria or suprapubic pain, making a UTI unlikely.
Plan to administer broad-spectrum antibiotic medication. Endometritis is a bacterial infection requiring IV broad-spectrum antibiotics, such as clindamycin and gentamicin, to prevent further complications.
Administer an oxytocic medication. Oxytocic agents like oxytocin or methylergonovine help contract the uterus, promoting lochia drainage and reducing bacterial growth, which helps resolve infection.
Apply ice packs to the breasts. This is used to relieve breast engorgement, but the primary concern is infection, not breast discomfort.
Encourage the client to increase fluid intake. Hydration is important but does not directly treat endometritis, making it a lower priority.
Initiate anticoagulant therapy. This is necessary for DVT management, but the client does not have symptoms of a clotting disorder.
Temperature. Fever is a key sign of infection, and monitoring temperature helps assess the effectiveness of antibiotic therapy.
Lochia amount and odor. Foul-smelling lochia is a major sign of endometritis, and monitoring for changes in amount or color helps evaluate treatment progress.
Bladder distension. The client is voiding frequently without difficulty, making bladder monitoring unnecessary.
Integrity of the nipples. This is only relevant for breastfeeding clients, and the client is bottle-feeding, making it not applicable.
Circumference of lower extremities. This is monitored for DVT progression, which is not suspected in this client.

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Correct Answer is B

Explanation

A. "I should place my baby in the car seat at a 50-degree angle." The correct car seat angle for a newborn is approximately 30-45 degrees. A steeper angle, such as 50 degrees, may increase the risk of the infant slumping forward, potentially leading to airway obstruction. Keeping the car seat reclined properly helps maintain an open airway and provides optimal support for the newborn's head and neck.
B. "I will place the retainer clip at the level of my baby's armpits." The chest clip should always be positioned at armpit level to ensure the harness straps remain secure and properly fitted. Placing the clip too low can allow the infant to slip out of the harness in a crash, while placing it too high may cause discomfort or breathing difficulties. This positioning provides maximum safety in case of a collision.
C. "I will place a thick, soft pad behind my baby's back." Extra padding, such as blankets or soft inserts not provided by the car seat manufacturer, should not be placed behind or around the baby. These can interfere with proper harness positioning and reduce the effectiveness of the car seat in a crash. Instead, parents should use only approved inserts or rolled blankets placed along the sides for support if needed.
D. "I can turn the car seat so it faces forward when my baby weighs 15 pounds." Infants should remain in a rear-facing car seat until they reach the highest weight or height limit specified by the car seat manufacturer, typically at least 2 years of age. Rear-facing seats provide better protection for the infant’s head, neck, and spine in the event of a crash. Turning the car seat forward too early increases the risk of serious injury.

Correct Answer is []

Explanation

Hypoglycemia. The newborn is jittery, has a weak cry, mottled extremities, acrocyanosis, and rapid respirations (72/min), which are classic signs of neonatal hypoglycemia. The risk is increased because the newborn is large for gestational age (4,366 g or 9 lb 10 oz). Newborns with excess birth weight often experience hyperinsulinemia, leading to a rapid drop in blood glucose after birth.
Kernicterus. This condition is caused by severe hyperbilirubinemia, but there is no indication of jaundice or elevated bilirubin levels in this newborn.
Congenital Syphilis. The mother was treated for syphilis in the first trimester and has a negative RPR/VDRL test, meaning the newborn is not at risk for congenital syphilis.
Neonatal Abstinence Syndrome. The newborn's urine drug screen was positive for marijuana but negative for opiates, cocaine, or amphetamines, which are the primary substances causing withdrawal symptoms in neonates. Marijuana exposure does not typically cause jitteriness and weak cry associated with withdrawal.
Reinforce with the parent to feed the newborn. Feeding helps stabilize blood glucose levels by providing a source of carbohydrates. Newborns with hypoglycemia should be fed frequently to prevent further drops in glucose.
Anticipate a prescription to obtain a capillary blood glucose level. Since jitteriness and weak cry are signs of hypoglycemia, a capillary blood glucose test should be performed to confirm the diagnosis. Newborn blood glucose should be ≥40 mg/dL in the first 4 hours and ≥45 mg/dL after 4 hours of life.
Collect a urine specimen. This would be necessary if neonatal drug withdrawal or metabolic disorders were suspected, but in this case, hypoglycemia is the most likely cause of symptoms.
Monitor the newborn after receiving penicillin IM. The newborn does not require penicillin since the maternal syphilis test was negative.
Monitor the newborn while receiving phototherapy. Phototherapy is not needed because there is no mention of jaundice or hyperbilirubinemia.
Respiratory status. Hypoglycemia can lead to respiratory distress, apnea, or tachypnea. The newborn already has an elevated respiratory rate of 72/min, which requires close monitoring for signs of worsening distress.
Temperature. The newborn’s temperature is 36°C (96.8°F), which is below the normal range of 36.5–37.5°C (97.7–99.5°F). Hypoglycemia can cause cold stress, and hypothermia can further worsen low blood sugar levels, making temperature regulation a priority.
Skin integrity. This is important for babies receiving phototherapy or those with rashes, but it is not a primary concern for hypoglycemia.
Bilirubin levels. Since kernicterus is not suspected, bilirubin levels do not need monitoring at this time.
Environmental stimuli. This is important for newborns with neonatal abstinence syndrome, but since withdrawal is not suspected, it is not a priority.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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