A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.

Exhibits

Which of the following actions should the nurse take

Diagnostic results

Escherichia coli infection resulting in necrotizing enterocolitis Hgb 10g/dL

Platelet count 50,000 mm

WBC count 4,000 mm3

Answer and Explanation

The Correct Answer is A

The nurse should insert an orogastric decompression tube with low wall suction. The newborn has Escherichia coli infection resulting in necrotizing enterocolitis, which can cause abdominal distention, decreased activity level, and bloody stools. The newborn also has a superficial rash on the abdominal wall, which may indicate a bacterial infection. The presence of a fist clenching, thrashing, and crying during light palpation of the

abdomen may indicate pain caused by bowel distention. An orogastric decompression tube with low wall suction can help decompress the bowel and relieve abdominal distention.

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Correct Answer is B

Explanation

The client's cervical dilation and effacement indicate that she is in active labor and progressing rapidly. Because the client is already 8 cm dilated and has been in labor for only 1 hour, the nurse should recognize that the client is at risk for a rapid delivery, which can increase the risk of postpartum hemorrhage. The other options listed are not associated with cervical dilation and effacement during active labor.

A. Initiate oxytocin via continuous IV infusion. B. Place the client in the left-lateral position. C. Request that the provider insert an intrauterine pressure catheter. D. Exert continuous upward pressure on the presenting part.

Correct Answer is D

Explanation

A. Initiate oxytocin via continuous IV infusion: Oxytocin stimulates uterine contractions, which would increase pressure on the umbilical cord, further compromising fetal oxygenation. This action is contraindicated in the presence of a prolapsed cord.

B. Place the client in the left-lateral position: Although the left-lateral position improves uteroplacental perfusion, it does not relieve pressure on the prolapsed cord. Instead, the nurse should position the client in a knee-chest or Trendelenburg position to reduce cord compression.

C. Request that the provider insert an intrauterine pressure catheter: Intrauterine pressure catheters are contraindicated in cases of umbilical cord prolapse as they can worsen cord compression and fetal hypoxia.

D. Exert continuous upward pressure on the presenting part: This action helps relieve pressure on the umbilical cord, improving blood flow and oxygen supply to the fetus. The nurse should maintain this position while simultaneously calling for immediate assistance and preparing the client for an emergency cesarean delivery.

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A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation. Exhibits Which of the following actions should the nurse take

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a 2-day-old newborn who was born at 35 weeks of gestation.

Exhibits

Which of the following actions should the nurse take