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 A

Explanation

Choice A rationale
Decreased extremity edema is a positive sign in a client with deep vein thrombosis (DVT) 48 hours postpartum. DVT is a blood clot that forms in a vein deep in the body, often in the lower leg or thigh. Edema, or swelling, is a common symptom. A decrease in edema may indicate that the condition is improving.
Choice B rationale
Redness in the extremity is not a positive sign in a client with DVT1112. Redness can indicate inflammation or infection, which could suggest a worsening of the condition.
Choice C rationale
Leukocytosis, or an increase in the number of white blood cells, is not a positive sign in a client with DVT1112. It can indicate an infection or inflammation, which could suggest a worsening of the condition.
Choice D rationale
Tachycardia, or a fast heart rate, is not a positive sign in a client with DVT1112. It can indicate a response to decreased oxygen levels in the blood, which could suggest a worsening of the condition.

A. My ovulation will remain the same. B. My monthly menstrual period will be shorter. C. Premenstrual tension will no longer be present. D. Hormone replacements will be needed following this procedure.

Correct Answer is A

Explanation

Choice A rationale
Ovulation will indeed remain the same after a tubal ligation. The procedure involves blocking or sealing the fallopian tubes, which prevents the egg from reaching the uterus. However, the ovaries continue to release eggs.
Choice B rationale
A tubal ligation procedure does not affect the length of the menstrual period. The menstrual cycle is regulated by hormones, not the patency of the fallopian tubes.
Choice C rationale
Premenstrual tension or premenstrual syndrome (PMS) is not eliminated by tubal ligation. PMS is related to the hormonal changes that occur during the menstrual cycle.
Choice D rationale
Hormone replacements are not needed following a tubal ligation. The ovaries continue to produce hormones as they did before the procedure.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis. How should the nurse interpret the findings 24 hr later?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client following a tubal ligation procedure. Which statement by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a client immediately following the delivery of a stillborn fetus. Which of the following actions should the nurse take?

A nurse is caring for a client who is at 6 weeks of gestation and reports nausea and vomiting. Which of the following recommendations should the nurse make?

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 caring for a newborn immediately following birth who has a prescription for erythromycin ophthalmic ointment. The guardian refuses the medication. Which action should the nurse take?

A nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse notes a steady trickle of vaginal bleeding that does not stop with fundal massage. Which action should the nurse take?

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?