A nurse is caring for a client.
Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.
There are three tabs that contain separate categories of data.)

Inspect the perineum.

Massage the fundus.

Administer oxytocin.

Assist the client to void.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Inspecting the perineum does not address uterine atony, which is the leading cause of postpartum hemorrhage. Interventions should focus on uterine contraction to minimize bleeding.

Choice B rationale

Massaging the fundus stimulates uterine contractions, reducing uterine atony and preventing further hemorrhage. This is a first-line intervention for postpartum excessive bleeding.

Choice C rationale

Administering oxytocin enhances uterine contractions and is effective in managing hemorrhage. However, fundal massage is prioritized initially to assess uterine tone and response.

Choice D rationale

Assisting the client to void helps empty the bladder, which may improve uterine contraction. However, fundal massage is the most immediate measure to prevent further bleeding.

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Correct Answer is C

Explanation

Choice A rationale

Checking the newborn’s temperature every 8 hours is insufficient during phototherapy. Frequent monitoring every 2-4 hours ensures proper thermoregulation, essential to preventing hypothermia or hyperthermia risks.

Choice B rationale

Moisturizing lotions can interfere with phototherapy by altering light penetration. Additionally, these products might increase the risk of skin irritation or chemical burns under light exposure.

Choice C rationale

Repositioning every 2-3 hours evenly exposes all skin areas to light, optimizing bilirubin breakdown and preventing pressure ulcers, ensuring effective phototherapy outcomes and skin integrity.

Choice D rationale

Glucose water is not recommended for hyperbilirubinemia management. Adequate hydration through breastfeeding or formula feeding ensures bilirubin excretion without interfering with feeding schedules or therapy effectiveness. .

A. "I will check the identification badge of anyone who removes my baby from our room.”. B. "I should include a photo of my baby in any public birth announcements to social media.”. C. "I will allow my baby to sleep on the bed in my room when I am in the shower.”. D. "I should expect the nurses to carry my baby in their arms to the nursery.”.

Correct Answer is A

Explanation

Choice A rationale

Checking the identification badge ensures the individual removing the baby is authorized, reducing the risk of abduction. This is a recommended safety practice in hospital settings to protect newborns.

Choice B rationale

Including photos in public birth announcements on social media increases the risk of identity theft or child abduction. It is not recommended as part of newborn safety measures.

Choice C rationale

Allowing the baby to sleep on the bed without supervision risks accidental injury, such as falls or suffocation. Safe sleep practices emphasize supervised, separate sleeping areas.

Choice D rationale

Nurses are instructed to transport newborns in bassinets rather than in their arms to minimize risks such as drops, maintaining higher safety standards in hospital environments.

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A nurse is caring for a client.Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy.Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is providing teaching about newborn safety to a client who is being admitted for induction of labor.Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A client reports an intermittent dark brown vaginal discharge for the past three days.

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A nurse is caring for a client.
Which of the following interventions should the nurse perform? (Click on the exhibit tabs for additional information about the client.
There are three tabs that contain separate categories of data.)