A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?

Maternal blood pressure of 128/88.

Fetal heart rate baseline of 115 bpm.

Maternal heart rate of 128 bpm.

Maternal respiratory rate of 18 breaths per minute.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A maternal blood pressure of 128/88 mm Hg is within normal limits for a pregnant woman. Regular monitoring is necessary, but no immediate follow-up is required unless symptoms of preeclampsia appear.

Choice B rationale

A fetal heart rate baseline of 115 bpm is within the normal range (110-160 bpm). This does not require immediate follow-up and is a reassuring sign of fetal well-being.

Choice C rationale

A maternal heart rate of 128 bpm is elevated (tachycardia) and may indicate distress, infection, dehydration, or other underlying conditions. This requires immediate follow-up to identify and address the cause.

Choice D rationale

A maternal respiratory rate of 18 breaths per minute is within the normal range (12-20 breaths per minute) and does not require immediate follow-up.

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Correct Answer is B

Explanation

Choice A rationale

Accidental lacerations are possible during a cesarean delivery, but they are typically managed quickly and are not the most critical issue immediately after birth.

Choice B rationale

Respiratory distress is the priority assessment for a newborn following a cesarean delivery because cesarean births can increase the risk of transient tachypnea or other respiratory complications due to the lack of labor-induced respiratory adaptation.

Choice C rationale

Hypothermia is a concern for all newborns, but respiratory distress takes precedence in the immediate post-delivery period, especially following cesarean delivery.

Choice D rationale

Acrocyanosis is a common and typically benign condition in newborns, not requiring immediate intervention compared to respiratory distress.

A. "The best way to determine if your baby can hear is to clap your hands loudly and see if she startles.” B. "Look at how she looks at you when you speak. That's a good sign.” C. "We do routine hearing screenings on newborns. You'll know before you leave the hospital if additional evaluation is recommended.”. D. "There is no need to worry about that. Most forms of hearing loss are not inherited.”

Correct Answer is C

Explanation

Choice A rationale

Clapping hands to assess hearing is not a reliable method and could startle the baby for reasons unrelated to hearing ability.

Choice B rationale

While a newborn might respond to visual stimuli, this is not a definitive method to assess hearing.

Choice C rationale

Routine hearing screenings using objective tests are the best way to determine a newborn's hearing ability, providing accurate and early detection of potential hearing issues.

Choice D rationale

This statement is misleading, as some forms of hearing loss can be inherited. It's important to use accurate methods to assess newborn hearing.

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A nurse is caring for a client in labor at 39 weeks of gestation.Which of the following assessment findings requires follow-up?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn immediately following a scheduled cesarean delivery.Which of the following assessments is the nurse's priority?

Correct Answer is B

Explanation

A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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A nurse is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?