A nurse is attending to a newborn who was delivered at 39 weeks of gestation and is now 36 hours old.

The newborn has been breastfeeding 3 to 4 times per day and has voided once since birth but has not passed meconium stool yet.

Which of the following observations should the nurse report to the provider?

Glucose level

Head assessment finding sclera color

Respiratory rate

Intake and output

Answer and Explanation

The Correct Answer is D

Choice A rationale
While monitoring glucose levels is important in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice B rationale
While assessing the newborn’s head and sclera color is part of a comprehensive newborn examination, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice C rationale
While monitoring the newborn’s respiratory rate is crucial in newborn care, it is not specifically related to breastfeeding frequency and voiding patterns.
Choice D rationale
Monitoring intake and output is directly related to breastfeeding frequency and voiding patterns. A newborn who has been breastfeeding 3 to 4 times per day should have passed meconium stool by 36 hours old. The absence of meconium stool could indicate a problem and should be reported to the provider.

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Correct Answer is B

Explanation

Choice A rationale
Dehydration could be a result of prolonged nausea and vomiting, but it is not the primary condition. Dehydration is a complication, not the cause of the symptoms.
Choice B rationale
The patient is most likely experiencing Hyperemesis Gravidarum, a severe form of nausea and vomiting in pregnancy. It’s more extreme than the typical morning sickness experienced during pregnancy and can lead to weight loss and dehydration. The nurse should ensure the patient stays hydrated and monitor their weight. Antiemetic medications may be prescribed to help control the vomiting.
Choice C rationale
Gastroenteritis typically involves both vomiting and diarrhea, often accompanied by abdominal pain and fever. The patient’s symptoms do not indicate gastroenteritis.
Choice D rationale
Food poisoning is usually associated with consuming contaminated food or water and often involves symptoms such as abdominal cramps and diarrhea, which the patient does not report.

A. Vacuum-assisted delivery B. History of human papillomavirus C. Newborn weight 2.948 kg (6lb 8 oz) D. Labor induction with oxytocin .

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

Explanation

Choice A rationale
Vacuum-assisted delivery is indeed a risk factor for postpartum hemorrhage. This method of delivery can cause trauma to the birth canal, which can lead to increased bleeding after delivery.
Choice B rationale
A history of human papillomavirus (HPV) is not typically associated with an increased risk of postpartum hemorrhage.
Choice C rationale
The newborn’s weight, whether high or low, is not typically considered a risk factor for postpartum hemorrhage.
Choice D rationale
Labor induction with oxytocin is a risk factor for postpartum hemorrhage. Oxytocin is a drug that can cause the uterus to contract too much, leading to uterine atony (a condition where the uterus doesn’t contract properly after birth), which can result in postpartum hemorrhage.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who had a vaginal delivery 3 hours ago.Which of the following findings place the client at risk for postpartum hemorrhage? (Select all that apply)

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

Explanation

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