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 D

Explanation

Choice A rationale
Amniocentesis is not a surgical procedure that requires general anesthesia, so the client will not be asleep during the procedure.
Choice B rationale
Fasting is not typically required before an amniocentesis. The procedure involves inserting a thin needle into the amniotic sac to withdraw a small amount of fluid for testing. It does not involve the digestive system, so there is no need for the client to fast.
Choice C rationale
While the client may be in various positions during the procedure, lying on the side is not typically required. The position of the client during the procedure is determined by the location of the baby and the amniotic sac.
Choice D rationale
Emptying the bladder before the procedure can make it easier for the healthcare provider to access the uterus and amniotic sac. Therefore, this statement indicates an understanding of the teaching.

A. Hematuria B. BUN 40 mg/dL C. Leukorrhea D. Platelet count 90,000/mm .

Correct Answer is B

Explanation

Choice A rationale
Hematuria, or blood in the urine, is not a normal finding in pregnancy. It could indicate a urinary tract infection, kidney stones, or other kidney problems. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation.
Choice B rationale
A BUN (Blood Urea Nitrogen) level of 40 mg/dL is higher than the normal range, which is between 7 and 20 mg/dL17181920. This could indicate that the kidneys are not working properly. However, it could also be due to a high-protein diet, dehydration, or other factors.
Choice C rationale
Leukorrhea, or vaginal discharge, is a common symptom of pregnancy. It is usually thin, white or clear, and mild smelling. If the discharge is yellow, green, or gray, has a strong smell, or is accompanied by itching or burning, it could indicate an infection.
Choice D rationale
A platelet count of 90,000/mm is lower than the normal range, which is between 150,000 and 450,000/mm25. This could indicate a condition called thrombocytopenia, which can be caused by various conditions, including pregnancy25. However, without more information, it’s not possible to determine the significance of this finding in a client who is at 33 weeks of gestation25.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is at 35 weeks of gestation and has a prescription for an amniocentesis. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who is at 33 weeks of gestation. The nurse is assessing the client 24 hours later. How should the nurse interpret the findings?

Correct Answer is B

Explanation

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

A nurse is preparing to obtain a blood sample from a newborn’s heel. In what order should the nurse perform the procedure?

A nurse is providing care to a client who is receiving an epidural block with an opioid analgesic. Which of the following findings should the nurse monitor as a potential adverse effect of the medication?

A nurse is assessing a newborn who was born postterm. Which of the following findings should the nurse expect?

A nurse is assessing a postpartum client during a follow-up visit. What was the client’s score on the Edinburgh Postnatal Depression Screen?

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“A nurse is obtaining a 2-hr postprandial blood glucose from a patient. Which of the following actions should the nurse take?”

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